Healthcare Provider Details

I. General information

NPI: 1841674777
Provider Name (Legal Business Name): LIFESTREAM HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2015
Last Update Date: 06/11/2020
Certification Date: 06/11/2020
Deactivation Date: 06/04/2020
Reactivation Date: 06/11/2020

III. Provider practice location address

4000 MITCHELLVILLE RD B322
BOWIE MD
20716-3104
US

IV. Provider business mailing address

4000 MITCHELLVILLE RD B322
BOWIE MD
20716-3104
US

V. Phone/Fax

Practice location:
  • Phone: 301-860-0305
  • Fax: 301-860-0307
Mailing address:
  • Phone: 301-860-0305
  • Fax: 301-860-0307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: DR. SARAH ANN MERRITT
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 301-860-0305