Provider Demographics
NPI:1316030711
Name:QUALITY OF LIFE MEDICAL SPECIALTIES, PLLC
Entity Type:Organization
Organization Name:QUALITY OF LIFE MEDICAL SPECIALTIES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VERNA
Authorized Official - Middle Name:M
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-400-7765
Mailing Address - Street 1:6149 AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24019-3813
Mailing Address - Country:US
Mailing Address - Phone:540-400-7765
Mailing Address - Fax:540-400-7555
Practice Address - Street 1:6149 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24019-3813
Practice Address - Country:US
Practice Address - Phone:540-992-2225
Practice Address - Fax:540-344-7154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-30
Last Update Date:2018-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C09973Medicare ID - Type Unspecified