Provider Demographics
NPI:1902861016
Name:LIFETIME SKIN CARE CENTERS, LLC
Entity Type:Organization
Organization Name:LIFETIME SKIN CARE CENTERS, LLC
Other - Org Name:LIFETIME SKIN CARE CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DREW
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-288-6200
Mailing Address - Street 1:401 W MCGALLIARD RD
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-1828
Mailing Address - Country:US
Mailing Address - Phone:765-288-6200
Mailing Address - Fax:765-288-4131
Practice Address - Street 1:401 W MCGALLIARD RD
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-1828
Practice Address - Country:US
Practice Address - Phone:765-288-6200
Practice Address - Fax:765-288-4131
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN177860Medicare ID - Type Unspecified