Provider Demographics
NPI:1083683932
Name:LIFELONG HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:LIFELONG HEALTH CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:ESTES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-895-5433
Mailing Address - Street 1:PO BOX 220
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:AR
Mailing Address - Zip Code:72576-0220
Mailing Address - Country:US
Mailing Address - Phone:870-895-5433
Mailing Address - Fax:870-895-5430
Practice Address - Street 1:642 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:AR
Practice Address - Zip Code:72576-0220
Practice Address - Country:US
Practice Address - Phone:870-895-5433
Practice Address - Fax:870-895-5430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-14
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR155977002Medicaid
AR155977002Medicaid