Provider Demographics
NPI:1023189800
Name:LIFESPAN PRIMARY CARE LLC
Entity Type:Organization
Organization Name:LIFESPAN PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BEVERLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:208-736-7090
Mailing Address - Street 1:224 MARTIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-4542
Mailing Address - Country:US
Mailing Address - Phone:208-736-7090
Mailing Address - Fax:208-736-7089
Practice Address - Street 1:224 MARTIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4542
Practice Address - Country:US
Practice Address - Phone:208-736-7090
Practice Address - Fax:208-736-7089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP717A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty