=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932419363
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFETIME HEALTH TR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2010
-----------------------------------------------------
Last Update Date | 10/19/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 515 E CAREFREE HWY STE 484
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85085-8839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-521-2930
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 515 E CAREFREE HWY STE 484
-----------------------------------------------------
City | PHOENIX
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85085-8839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MGR
-----------------------------------------------------
Name | PROF. CK KLINE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 623-521-2930
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 00114
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------