Provider Demographics
NPI:1629489042
Name:LIFETIME HEALTH CENTER
Entity Type:Organization
Organization Name:LIFETIME HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RENE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCARTY
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:903-534-0773
Mailing Address - Street 1:1420 WSW LOOP 323
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-9347
Mailing Address - Country:US
Mailing Address - Phone:903-534-0773
Mailing Address - Fax:903-534-0880
Practice Address - Street 1:1420 WSW LOOP 323
Practice Address - Street 2:SUITE 100
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-9347
Practice Address - Country:US
Practice Address - Phone:903-534-0773
Practice Address - Fax:903-534-0880
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFETIME HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-05-20
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA01101363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty