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General NPI Number Information
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NPI Number | 1497299101
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Entity Type | Organization
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Legal Business Name | LIFESTYLES
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Dates
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Enumeration Date | 12/14/2016
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Last Update Date | 12/14/2016
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Provider Practice Location Address
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Address Line | 4385 E WILD ELK TRL
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City | FLAGSTAFF
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State | AZ
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Zip | 86004-7921
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Country | US
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Telephone | 928-326-0044
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Fax |
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Provider Business Mailing Address
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Address Line | 4385 E WILD ELK TRL
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City | FLAGSTAFF
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State | AZ
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Zip | 86004-7921
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Country | US
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Telephone | 928-326-0044
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MR. DWIGHT C BOYD
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Credential | N-A
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Telephone | 928-326-0044
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number |
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License Number State |
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