Provider Demographics
NPI:1689744963
Name:CENTER FOR LIFETIME HEALTH
Entity Type:Organization
Organization Name:CENTER FOR LIFETIME HEALTH
Other - Org Name:COLLEEN SHACKELFORD, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COLLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHACKELFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:208-342-7400
Mailing Address - Street 1:300 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712
Mailing Address - Country:US
Mailing Address - Phone:208-342-7400
Mailing Address - Fax:208-342-1879
Practice Address - Street 1:300 E BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712
Practice Address - Country:US
Practice Address - Phone:208-342-7400
Practice Address - Fax:208-342-1879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM5741207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDF41980Medicare UPIN
ID1378263Medicare PIN
IDE50516Medicare UPIN
IDS93400Medicare UPIN