Provider Demographics
NPI:1114205812
Name:LIFELONG WELLNESS CLINIC PLLC
Entity Type:Organization
Organization Name:LIFELONG WELLNESS CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:TIDROSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:254-629-1100
Mailing Address - Street 1:711 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EASTLAND
Mailing Address - State:TX
Mailing Address - Zip Code:76448-2534
Mailing Address - Country:US
Mailing Address - Phone:254-629-1100
Mailing Address - Fax:254-629-1104
Practice Address - Street 1:711 W MAIN ST
Practice Address - Street 2:
Practice Address - City:EASTLAND
Practice Address - State:TX
Practice Address - Zip Code:76448-2534
Practice Address - Country:US
Practice Address - Phone:254-629-1100
Practice Address - Fax:254-629-1104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-28
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN2319207Q00000X
TXP0309208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty