Provider Demographics
NPI:1245429216
Name:LIFESTYLE MEDICINE LLC
Entity Type:Organization
Organization Name:LIFESTYLE MEDICINE LLC
Other - Org Name:BRADLEY KANODE MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:KANODE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:505-425-2850
Mailing Address - Street 1:1301 8TH ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NM
Mailing Address - Zip Code:87701-4221
Mailing Address - Country:US
Mailing Address - Phone:505-425-2850
Mailing Address - Fax:505-425-2847
Practice Address - Street 1:1301 8TH ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4221
Practice Address - Country:US
Practice Address - Phone:505-425-2850
Practice Address - Fax:505-425-2847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2000216207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty