Healthcare Provider Details

I. General information

NPI: 1174714265
Provider Name (Legal Business Name): LIFETIME WELLNESS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2007
Last Update Date: 08/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 UPLAND AVE
BOULDER CO
80304-0830
US

IV. Provider business mailing address

PO BOX 876
NIWOT CO
80544-0876
US

V. Phone/Fax

Practice location:
  • Phone: 303-589-6802
  • Fax:
Mailing address:
  • Phone: 303-589-0680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number992045
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DIANE B BYINGTON
Title or Position: PRESIDENT
Credential: LCSW
Phone: 303-589-6802