Healthcare Provider Details

I. General information

NPI: 1275372302
Provider Name (Legal Business Name): LIFELONG WELLNESS OF OHIO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2024
Last Update Date: 05/20/2024
Certification Date: 05/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31054 STATE ROUTE 93
MC ARTHUR OH
45651-8925
US

IV. Provider business mailing address

1074 TIMES SQUARE BLVD
LAKEWOOD NJ
08701-5524
US

V. Phone/Fax

Practice location:
  • Phone: 732-691-0470
  • Fax:
Mailing address:
  • Phone: 732-691-0470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ISRAEL STEIN
Title or Position: MANAGER
Credential:
Phone: 732-691-0470