Provider Demographics
NPI:1093068371
Name:LIFETIME WOMEN'S HEALTH & FITNESS CENTERS P.C.
Entity Type:Organization
Organization Name:LIFETIME WOMEN'S HEALTH & FITNESS CENTERS P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:ELLISON
Authorized Official - Last Name:WING
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-395-7414
Mailing Address - Street 1:3575 BRIDGE RD
Mailing Address - Street 2:SUITE 8 PMB 433
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-1800
Mailing Address - Country:US
Mailing Address - Phone:757-395-7414
Mailing Address - Fax:757-923-4607
Practice Address - Street 1:1037 CHAMPIONS WAY
Practice Address - Street 2:SUITE 300
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-3764
Practice Address - Country:US
Practice Address - Phone:757-395-7414
Practice Address - Fax:757-923-4607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101240033174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG36805Medicare UPIN