Provider Demographics
NPI:1366688129
Name:LIFE LITE TESTING INC
Entity Type:Organization
Organization Name:LIFE LITE TESTING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:W
Authorized Official - Last Name:BERENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-257-8102
Mailing Address - Street 1:700 COLORADO BLVD
Mailing Address - Street 2:STE 223
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80206-4084
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:700 COLORADO BLVD
Practice Address - Street 2:STE 223
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80206-4084
Practice Address - Country:US
Practice Address - Phone:720-257-8102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-29
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO30813207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOB4314Medicare PIN