Healthcare Provider Details

I. General information

NPI: 1982933107
Provider Name (Legal Business Name): LIFETIME MEDICAL CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2009
Last Update Date: 08/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14244 HIGHWAY 515 N SUITE 100
ELLIJAY GA
30536
US

IV. Provider business mailing address

14244 HIGHWAY 515 N SUITE 100
ELLIJAY GA
30536
US

V. Phone/Fax

Practice location:
  • Phone: 706-698-5433
  • Fax:
Mailing address:
  • Phone: 706-698-5433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number051241
License Number StateGA

VIII. Authorized Official

Name: LEE KENT
Title or Position: ADMINISTRATOR
Credential:
Phone: 706-698-5433