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General NPI Number Information
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NPI Number | 1093068371
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Entity Type | Organization
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Legal Business Name | LIFETIME WOMEN'S HEALTH & FITNESS CENTERS P.C.
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Dates
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Enumeration Date | 10/24/2012
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Last Update Date | 10/24/2012
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Provider Practice Location Address
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Address Line | 1037 CHAMPIONS WAY SUITE 300
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City | SUFFOLK
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State | VA
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Zip | 23435-3764
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Country | US
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Telephone | 757-395-7414
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Fax | 757-923-4607
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Provider Business Mailing Address
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Address Line | 3575 BRIDGE RD SUITE 8 PMB 433
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City | SUFFOLK
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State | VA
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Zip | 23435-1800
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Country | US
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Telephone | 757-395-7414
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Fax | 757-923-4607
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Authorized Official
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Title or Position | PRESIDENT
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Name | EDWARD ELLISON WING
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Credential | MD
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Telephone | 757-395-7414
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 0101240033
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License Number State | VA
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