Provider Demographics
NPI:1609054501
Name:LIFESTYLE MEDICAL, LLC
Entity Type:Organization
Organization Name:LIFESTYLE MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DARREL
Authorized Official - Middle Name:L
Authorized Official - Last Name:ENGLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:325-617-2181
Mailing Address - Street 1:2205 W BEAUREGARD AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76901-3701
Mailing Address - Country:US
Mailing Address - Phone:325-617-2181
Mailing Address - Fax:325-617-2479
Practice Address - Street 1:2205 W BEAUREGARD AVE
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76901-3701
Practice Address - Country:US
Practice Address - Phone:325-617-2181
Practice Address - Fax:325-617-2479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-04
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX532817OtherBC/BS
TX1954927Medicaid
TX6118810001Medicare NSC