Provider Demographics
NPI:1033302203
Name:LIFEPLEX DIAGNOSTIC CENTER, L.L.C.
Entity Type:Organization
Organization Name:LIFEPLEX DIAGNOSTIC CENTER, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:BYRON
Authorized Official - Middle Name:M
Authorized Official - Last Name:HOLM
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:574-936-7777
Mailing Address - Street 1:2855 MILLER DR
Mailing Address - Street 2:SUITE 113
Mailing Address - City:PLYMOUTH
Mailing Address - State:IN
Mailing Address - Zip Code:46563-8091
Mailing Address - Country:US
Mailing Address - Phone:574-941-1090
Mailing Address - Fax:
Practice Address - Street 1:2855 MILLER DR
Practice Address - Street 2:SUITE 113
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-8091
Practice Address - Country:US
Practice Address - Phone:574-941-1090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-21
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN261QR0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200882130Medicaid
IN200882130Medicaid