Healthcare Provider Details

I. General information

NPI: 1104683200
Provider Name (Legal Business Name): LIFESTYLE CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2024
Last Update Date: 03/05/2024
Certification Date: 03/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

977 AZALEE HESTER WHARTON WAY NW
ATLANTA GA
30318-4559
US

IV. Provider business mailing address

977 AZALEE HESTER WHARTON WAY NW
ATLANTA GA
30318-4559
US

V. Phone/Fax

Practice location:
  • Phone: 404-429-2226
  • Fax:
Mailing address:
  • Phone: 404-429-2226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RB0002X
TaxonomyObesity Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DENIECE NICOLE JOHNSON
Title or Position: OWNER
Credential: MD, DABOM
Phone: 404-429-2226