Provider Demographics
NPI:1376974923
Name:LIFESTART NATIONAL FITNESS
Entity Type:Organization
Organization Name:LIFESTART NATIONAL FITNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:
Authorized Official - Last Name:FLANAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-627-1300
Mailing Address - Street 1:125 S WACKER DR
Mailing Address - Street 2:SUITE 2155
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-4424
Mailing Address - Country:US
Mailing Address - Phone:312-627-1300
Mailing Address - Fax:312-627-1317
Practice Address - Street 1:125 S WACKER DR
Practice Address - Street 2:SUITE 2155
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60606-4424
Practice Address - Country:US
Practice Address - Phone:312-627-1300
Practice Address - Fax:312-627-1317
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2478133V00000X
PADN003881133V00000X
IL041344664163W00000X
246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty