Provider Demographics
NPI:1811553555
Name:DIET OF A LIFETIME, LLC
Entity Type:Organization
Organization Name:DIET OF A LIFETIME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:C
Authorized Official - Last Name:GOLDMON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:870-540-9114
Mailing Address - Street 1:420 SANDY BAYOU LN
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-6555
Mailing Address - Country:US
Mailing Address - Phone:870-850-0351
Mailing Address - Fax:870-850-0351
Practice Address - Street 1:123 S PINE ST
Practice Address - Street 2:
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71601-4222
Practice Address - Country:US
Practice Address - Phone:870-540-9114
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-17
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center