Provider Demographics
NPI:1265840037
Name:LIFETIME MEDICAL CARE PLLC
Entity Type:Organization
Organization Name:LIFETIME MEDICAL CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER/PROVIDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:DAMSCHRODER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:928-237-9014
Mailing Address - Street 1:3101 CLEARWATER DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86305-7180
Mailing Address - Country:US
Mailing Address - Phone:928-237-9014
Mailing Address - Fax:928-237-9063
Practice Address - Street 1:3101 CLEARWATER DR
Practice Address - Street 2:SUITE B
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86305-7180
Practice Address - Country:US
Practice Address - Phone:928-237-9014
Practice Address - Fax:928-237-9063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-24
Last Update Date:2015-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP7289261QR1300X
AZRN073139261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAP7289OtherNURSE PRACTITIONER LICENSE NUMBER