Healthcare Provider Details

I. General information

NPI: 1881025369
Provider Name (Legal Business Name): LIFESTYLE DIABETIC SUPPORT SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2013
Last Update Date: 09/09/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10210 N 32ND ST STE C7
PHOENIX AZ
85028-3826
US

IV. Provider business mailing address

10210 N 32ND ST STE C7
PHOENIX AZ
85028-3826
US

V. Phone/Fax

Practice location:
  • Phone: 602-675-1576
  • Fax: 602-610-5844
Mailing address:
  • Phone: 602-675-1576
  • Fax: 602-610-5844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207KI0005X
TaxonomyClinical & Laboratory Immunology (Allergy & Immunology) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. TIMOTHY JOSEPH YOUKHANA
Title or Position: OWNER
Credential: PHARM D
Phone: 602-675-0887