Provider Demographics
NPI:1750055216
Name:LIFETIME HEALTH MEDICAL GROUP INC
Entity Type:Organization
Organization Name:LIFETIME HEALTH MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:DUCONGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:786-238-7982
Mailing Address - Street 1:11410 N KENDALL DR STE 307
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-1031
Mailing Address - Country:US
Mailing Address - Phone:786-238-7982
Mailing Address - Fax:305-463-1293
Practice Address - Street 1:11410 N KENDALL DR STE 307
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-1031
Practice Address - Country:US
Practice Address - Phone:786-238-7982
Practice Address - Fax:305-463-1293
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-06
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center