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General NPI Number Information
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NPI Number | 1366823932
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Entity Type | Organization
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Legal Business Name | LIFESTYLE MEDICINE, INC.
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Dates
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Enumeration Date | 06/09/2015
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Last Update Date | 06/09/2015
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Provider Practice Location Address
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Address Line | 2405 E SKELLY DR
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City | TULSA
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State | OK
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Zip | 74105-6006
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Country | US
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Telephone | 918-488-9874
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Fax | 918-587-3437
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Provider Business Mailing Address
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Address Line | 2405 E SKELLY DR
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City | TULSA
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State | OK
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Zip | 74105-6006
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Country | US
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Telephone | 918-488-9874
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Fax | 918-587-3437
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Authorized Official
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Title or Position | OWNER
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Name | DR. RENAE MAYER
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Credential | MD
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Telephone | 918-488-9874
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RH0000X
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Taxonomy Name | Hematology (Internal Medicine) Physician
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License Number | 22105
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License Number State | OK
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