Healthcare Provider Details

I. General information

NPI: 1114449238
Provider Name (Legal Business Name): LIFEPLEX MEDICAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2017
Last Update Date: 05/25/2021
Certification Date: 05/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2855 MILLER DR STE 117
PLYMOUTH IN
46563-8091
US

IV. Provider business mailing address

2855 MILLER DR STE 117
PLYMOUTH IN
46563-8091
US

V. Phone/Fax

Practice location:
  • Phone: 574-936-7777
  • Fax: 574-941-1072
Mailing address:
  • Phone: 574-936-7777
  • Fax: 574-941-1072

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01024911A
License Number StateIN

VIII. Authorized Official

Name: BYRON HOLM
Title or Position: MD
Credential: MD
Phone: 574-936-7777