Provider Demographics
NPI:1235363409
Name:LIFESTREAM HEALTH CENTER PA
Entity Type:Organization
Organization Name:LIFESTREAM HEALTH CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:C
Authorized Official - Last Name:CHARLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:972-304-6400
Mailing Address - Street 1:705 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019
Mailing Address - Country:US
Mailing Address - Phone:972-304-6400
Mailing Address - Fax:972-304-6455
Practice Address - Street 1:705 MAIN ST
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-4742
Practice Address - Country:US
Practice Address - Phone:972-304-6400
Practice Address - Fax:972-304-6455
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFESREAM HEALTH CENTER PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-04
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH6110174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXH6110OtherTEXAS MEDICAL BOARD LICENSE
TXH6110OtherTEXAS MEDICAL BOARD LICENSE