Healthcare Provider Details

I. General information

NPI: 1609054501
Provider Name (Legal Business Name): LIFESTYLE MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2008
Last Update Date: 10/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2205 W BEAUREGARD AVE
SAN ANGELO TX
76901-3701
US

IV. Provider business mailing address

2205 W BEAUREGARD AVE
SAN ANGELO TX
76901-3701
US

V. Phone/Fax

Practice location:
  • Phone: 325-617-2181
  • Fax: 325-617-2479
Mailing address:
  • Phone: 325-617-2181
  • Fax: 325-617-2479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: DARREL L ENGLE
Title or Position: MEMBER
Credential:
Phone: 325-617-2181