Provider Demographics
NPI:1669981775
Name:LIFETIME HEALTH CARE SERVICES, LLC
Entity type:Organization
Organization Name:LIFETIME HEALTH CARE SERVICES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:AYENI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-985-0456
Mailing Address - Street 1:40 AUBURN PARK DRIVE SUITE G
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30011-3644
Mailing Address - Country:US
Mailing Address - Phone:678-985-0456
Mailing Address - Fax:678-985-0457
Practice Address - Street 1:40 AUBURN PARK DR STE G
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:GA
Practice Address - Zip Code:30011-3644
Practice Address - Country:US
Practice Address - Phone:678-985-0456
Practice Address - Fax:678-985-0457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA067R0355251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========Medicaid