Provider Demographics
NPI:1457866535
Name:LIFE CYCLE OB/GYN, LLC
Entity Type:Organization
Organization Name:LIFE CYCLE OB/GYN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:SIREY
Authorized Official - Last Name:SIGOUIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-405-4543
Mailing Address - Street 1:2739 FELTON DR
Mailing Address - Street 2:
Mailing Address - City:EAST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:30344-3603
Mailing Address - Country:US
Mailing Address - Phone:404-766-8371
Mailing Address - Fax:404-767-3926
Practice Address - Street 1:428 WINN CT
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1726
Practice Address - Country:US
Practice Address - Phone:404-766-8371
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-11
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA300035567EMedicaid