Healthcare Provider Details

I. General information

NPI: 1053509216
Provider Name (Legal Business Name): LIFETIME FAMILY MEDICINE,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2007
Last Update Date: 03/10/2023
Certification Date: 03/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7869 VILLA RICA HWY
DALLAS GA
30157-8638
US

IV. Provider business mailing address

7869 VILLA RICA HWY
DALLAS GA
30157-8638
US

V. Phone/Fax

Practice location:
  • Phone: 770-459-8449
  • Fax:
Mailing address:
  • Phone: 770-459-8449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number052082
License Number StateGA

VIII. Authorized Official

Name: MRS. LISA H MILES
Title or Position: PRACTICE MANAGER
Credential:
Phone: 770-459-8449