Provider Demographics
NPI:1699188359
Name:LIFESTYLES MEDICAL
Entity Type:Organization
Organization Name:LIFESTYLES MEDICAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:MR
Authorized Official - First Name:RAND
Authorized Official - Middle Name:
Authorized Official - Last Name:SALANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-542-2638
Mailing Address - Street 1:107 MONMOUTH RD
Mailing Address - Street 2:SUITE 104 D
Mailing Address - City:WEST LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07764-1021
Mailing Address - Country:US
Mailing Address - Phone:732-542-2638
Mailing Address - Fax:732-542-2620
Practice Address - Street 1:107 MONMOUTH RD
Practice Address - Street 2:SUITE 104 D
Practice Address - City:WEST LONG BRANCH
Practice Address - State:NJ
Practice Address - Zip Code:07764-1021
Practice Address - Country:US
Practice Address - Phone:732-542-2638
Practice Address - Fax:732-542-2620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-10
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC055397001041C0700X
NJ25MB07769000208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0600410687OtherCORPORATE ID NUMBER