Provider Demographics
NPI:1073068029
Name:CENTER FOR LIFESTYLE HEALTH A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:CENTER FOR LIFESTYLE HEALTH A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:DAVE
Authorized Official - Middle Name:A
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-496-4281
Mailing Address - Street 1:2079 COMPTON AVE BLDG 3A
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92881-7284
Mailing Address - Country:US
Mailing Address - Phone:951-496-4281
Mailing Address - Fax:
Practice Address - Street 1:2079 COMPTON AVE BLDG 3A
Practice Address - Street 2:SUITE 102
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92881-7284
Practice Address - Country:US
Practice Address - Phone:951-496-4281
Practice Address - Fax:951-496-4222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-19
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA659632083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty