Provider Demographics
NPI:1073009338
Name:LIFETIME HEALTHCHOICE LLC
Entity Type:Organization
Organization Name:LIFETIME HEALTHCHOICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/NURSE PRACTITIONER
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:YEBOAH
Authorized Official - Last Name:KORDIE
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:973-641-8836
Mailing Address - Street 1:36 HAWTHORNE PL APT 4M
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-3277
Mailing Address - Country:US
Mailing Address - Phone:973-641-8836
Mailing Address - Fax:
Practice Address - Street 1:36 HAWTHORNE PL APT 4M
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-3277
Practice Address - Country:US
Practice Address - Phone:973-641-8836
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-10
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities