Provider Demographics
NPI:1477632578
Name:LIFELINE STOP SMOKING CLINIC, LLC
Entity Type:Organization
Organization Name:LIFELINE STOP SMOKING CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:SCANLAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:316-640-0804
Mailing Address - Street 1:650 N CARRIAGE PKWY
Mailing Address - Street 2:SUITE 135
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-4507
Mailing Address - Country:US
Mailing Address - Phone:316-640-0804
Mailing Address - Fax:316-685-8247
Practice Address - Street 1:650 N CARRIAGE PKWY
Practice Address - Street 2:SUITE 135
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67208-4507
Practice Address - Country:US
Practice Address - Phone:316-640-0804
Practice Address - Fax:316-685-8247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS17663261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS103516OtherBCBS NON-PAR. PROVIDER #