Healthcare Provider Details

I. General information

NPI: 1255581583
Provider Name (Legal Business Name): LIFESTYLE MEDICAL MANUFACTURING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2008
Last Update Date: 09/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6479 E 22ND ST
TUCSON AZ
85710-5115
US

IV. Provider business mailing address

6479 E 22ND ST
TUCSON AZ
85710-5115
US

V. Phone/Fax

Practice location:
  • Phone: 520-323-0099
  • Fax: 520-290-6905
Mailing address:
  • Phone: 520-323-0099
  • Fax: 520-290-6905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License NumberBHAD1362
License Number StateAZ

VIII. Authorized Official

Name: RONALD MIDDLETON
Title or Position: OWNER
Credential:
Phone: 520-323-0099