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General NPI Number Information
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NPI Number | 1477632578
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Entity Type | Organization
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Legal Business Name | LIFELINE STOP SMOKING CLINIC, LLC
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Dates
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Enumeration Date | 11/02/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 650 N CARRIAGE PKWY SUITE 135
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City | WICHITA
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State | KS
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Zip | 67208-4507
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Country | US
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Telephone | 316-640-0804
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Fax | 316-685-8247
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Provider Business Mailing Address
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Address Line | 650 N CARRIAGE PKWY SUITE 135
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City | WICHITA
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State | KS
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Zip | 67208-4507
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Country | US
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Telephone | 316-640-0804
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Fax | 316-685-8247
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Authorized Official
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Title or Position | OWNER/MANAGING PARTNER
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Name | DR. TIMOTHY SCANLAN
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Credential | MD
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Telephone | 316-640-0804
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | 17663
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License Number State | KS
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