Provider Demographics
NPI:1043372279
Name:LIFEWORKS AESTHETIC CENTER, PSC
Entity Type:Organization
Organization Name:LIFEWORKS AESTHETIC CENTER, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:A
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:270-444-0119
Mailing Address - Street 1:242 BERGER RD
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-4522
Mailing Address - Country:US
Mailing Address - Phone:270-444-0119
Mailing Address - Fax:270-444-9129
Practice Address - Street 1:242 BERGER RD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-4522
Practice Address - Country:US
Practice Address - Phone:270-444-0119
Practice Address - Fax:270-444-9129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY15202174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64095334Medicaid
KY9443Medicare PIN
KYC74949Medicare UPIN