=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467664276
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE CYCLE OBGYN, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2007
-----------------------------------------------------
Last Update Date | 03/18/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2739 FELTON DR
-----------------------------------------------------
City | EAST POINT
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30344-3603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-766-8371
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2739 FELTON DR
-----------------------------------------------------
City | EAST POINT
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30344-3603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-766-8371
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE MANAGER
-----------------------------------------------------
Name | ANNE SIGOUIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-766-8371
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207VX0000X
-----------------------------------------------------
Taxonomy Name | Obstetrics Physician
-----------------------------------------------------
License Number | 053504
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------