Provider Demographics
NPI:1881025369
Name:LIFESTYLE DIABETIC SUPPORT SERVICES, LLC
Entity Type:Organization
Organization Name:LIFESTYLE DIABETIC SUPPORT SERVICES, LLC
Other - Org Name:ASSYRIAN FAMILY HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:YOUKHANA
Authorized Official - Suffix:
Authorized Official - Credentials:PHARM D
Authorized Official - Phone:602-675-0887
Mailing Address - Street 1:10210 N 32ND ST STE C7
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85028-3826
Mailing Address - Country:US
Mailing Address - Phone:602-675-1576
Mailing Address - Fax:602-610-5844
Practice Address - Street 1:10210 N 32ND ST STE C7
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85028-3826
Practice Address - Country:US
Practice Address - Phone:602-675-1576
Practice Address - Fax:602-610-5844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207KI0005X
IL291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KI0005XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyClinical & Laboratory ImmunologyGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty