Provider Demographics
NPI:1477614311
Name:LIFE CHANGES HEALTH CARE CLINIC
Entity Type:Organization
Organization Name:LIFE CHANGES HEALTH CARE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:LYNDON
Authorized Official - Middle Name:C
Authorized Official - Last Name:CAPON
Authorized Official - Suffix:
Authorized Official - Credentials:MD, ARNP, ND
Authorized Official - Phone:425-750-0881
Mailing Address - Street 1:PO BOX 12608
Mailing Address - Street 2:
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98082-0608
Mailing Address - Country:US
Mailing Address - Phone:425-252-6484
Mailing Address - Fax:
Practice Address - Street 1:2820 HEWITT AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-3820
Practice Address - Country:US
Practice Address - Phone:425-252-6484
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANT00000478175F00000X
WAAP30006112363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No175F00000XOther Service ProvidersNaturopathGroup - Multi-Specialty