=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992102180
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFESPRING MEDICAL SERVICES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2014
-----------------------------------------------------
Last Update Date | 12/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1036 SHARON DR
-----------------------------------------------------
City | JEFFERSONVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47130-4522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-280-2080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1036 SHARON DR
-----------------------------------------------------
City | JEFFERSONVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47130-4522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-280-2080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | INCORPORATOR
-----------------------------------------------------
Name | MR. TERRY STAWAR
-----------------------------------------------------
Credential | ED.D
-----------------------------------------------------
Telephone | 812-206-1234
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------