Healthcare Provider Details

I. General information

NPI: 1639275712
Provider Name (Legal Business Name): LIFETIME HEALTH CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

868 NORTHWEST GARDEN VALLEY BOULEVARD
ROSEBURG OR
97470-1959
US

IV. Provider business mailing address

868 NW GARDEN VALLEY BLVD
ROSEBURG OR
97470-1959
US

V. Phone/Fax

Practice location:
  • Phone: 541-673-4513
  • Fax: 541-672-6384
Mailing address:
  • Phone: 541-673-4513
  • Fax: 541-672-6384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN D SPROED
Title or Position: PHYSICIAN OWNER
Credential: MD
Phone: 541-673-4513