MEDICARE: LIFESTYLE MEDICAL SOLUTIONS 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	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1811430812
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFESTYLE MEDICAL SOLUTIONS LLC

Provider Business Mailing Address
First Line	:	3998 INDIANOLA AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43214-3158
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3998 INDIANOLA AVE
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43214-3158
Country	:	US
Telephone Number	:	614-573-7746
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	KEVIN KEMP
Credential	:
Telephone Number	:	6146146191311

Provider Enumeration Date	:	11/22/2016
Last Update Date	:	11/22/2016

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