Healthcare Provider Details

I. General information

NPI: 1477632578
Provider Name (Legal Business Name): LIFELINE STOP SMOKING CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 N CARRIAGE PKWY SUITE 135
WICHITA KS
67208-4507
US

IV. Provider business mailing address

650 N CARRIAGE PKWY SUITE 135
WICHITA KS
67208-4507
US

V. Phone/Fax

Practice location:
  • Phone: 316-640-0804
  • Fax: 316-685-8247
Mailing address:
  • Phone: 316-640-0804
  • Fax: 316-685-8247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number17663
License Number StateKS

VIII. Authorized Official

Name: DR. TIMOTHY SCANLAN
Title or Position: OWNER/MANAGING PARTNER
Credential: MD
Phone: 316-640-0804