Provider Demographics
NPI:1639275712
Name:LIFETIME HEALTH CLINIC
Entity Type:Organization
Organization Name:LIFETIME HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:SPROED
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:541-673-4513
Mailing Address - Street 1:868 NW GARDEN VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-1959
Mailing Address - Country:US
Mailing Address - Phone:541-673-4513
Mailing Address - Fax:541-672-6384
Practice Address - Street 1:868 NORTHWEST GARDEN VALLEY BOULEVARD
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97470-1959
Practice Address - Country:US
Practice Address - Phone:541-673-4513
Practice Address - Fax:541-672-6384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR115984Medicare ID - Type UnspecifiedMEDICARE GROUP ID NUMBER