Provider Demographics
NPI:1053509216
Name:LIFETIME FAMILY MEDICINE,LLC
Entity Type:Organization
Organization Name:LIFETIME FAMILY MEDICINE,LLC
Other - Org Name:LIFETIME FAMILY MEDICINE LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:H
Authorized Official - Last Name:MILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-459-8449
Mailing Address - Street 1:7869 VILLA RICA HWY
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30157-8638
Mailing Address - Country:US
Mailing Address - Phone:770-459-8449
Mailing Address - Fax:
Practice Address - Street 1:7869 VILLA RICA HWY
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30157-8638
Practice Address - Country:US
Practice Address - Phone:770-459-8449
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-11
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
GA052082261QS1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder DiagnosticGroup - Single Specialty