Provider Demographics
NPI:1992214548
Name:LIFESTYLE MEDICAL CENTER, PLLC
Entity Type:Organization
Organization Name:LIFESTYLE MEDICAL CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GERRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:LANGSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-747-5555
Mailing Address - Street 1:4505 S HARVARD AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2905
Mailing Address - Country:US
Mailing Address - Phone:918-747-5555
Mailing Address - Fax:
Practice Address - Street 1:4505 S HARVARD AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2905
Practice Address - Country:US
Practice Address - Phone:918-747-5555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty