MEDICARE: LIFEBRITE PHYSICIAN GROUP LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1740751221
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFEBRITE PHYSICIAN GROUP LLC

Provider Business Mailing Address
First Line	:	3970 FIVE FORKS TRICKUM RD SW STE A
Second Line	:
City	:	LILBURN
State	:	GA
Zip	:	30047-2339
Country	:	US
Telephone Number	:	855-359-8629
Fax Number	:	678-310-1355

Provider Business Practice Location Address
First Line	:	3970 FIVE FORKS TRICKUM RD SW STE A
Second Line	:
City	:	LILBURN
State	:	GA
Zip	:	30047-2339
Country	:	US
Telephone Number	:	855-359-8629
Fax Number	:	678-310-1355

Authorized Official
Title or Position	:	CEO
Name	:	MR. CHRISTIAN FLETCHER
Credential	:
Telephone Number	:	855-359-8629

Provider Enumeration Date	:	12/10/2018
Last Update Date	:	12/10/2018

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