Provider Demographics
NPI:1972273282
Name:OPERATION LIFESTYLE REDESIGN GROUP LLC
Entity Type:Organization
Organization Name:OPERATION LIFESTYLE REDESIGN GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT OF CLINICAL OPERATIO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:DAVAR
Authorized Official - Last Name:PERVIS
Authorized Official - Suffix:SR
Authorized Official - Credentials:APRN
Authorized Official - Phone:203-957-3938
Mailing Address - Street 1:33 DIXWELL AVE STE 278
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-3403
Mailing Address - Country:US
Mailing Address - Phone:203-957-3938
Mailing Address - Fax:866-266-4842
Practice Address - Street 1:83 WOOSTER HEIGHTS
Practice Address - Street 2:SUITE #125
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810
Practice Address - Country:US
Practice Address - Phone:203-957-3938
Practice Address - Fax:866-266-4842
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-17
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care