Provider Demographics
NPI:1700127941
Name:LIFETIME OPTIMIZATION, INC.
Entity type:Organization
Organization Name:LIFETIME OPTIMIZATION, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:ROYCE
Authorized Official - Last Name:PENDERGRAFT
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:503-327-8713
Mailing Address - Street 1:6105 SW MACADAM AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3640
Mailing Address - Country:US
Mailing Address - Phone:503-327-8713
Mailing Address - Fax:
Practice Address - Street 1:6105 SW MACADAM AVE STE 100
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3640
Practice Address - Country:US
Practice Address - Phone:503-327-8713
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-13
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246ZE0500X
OR22271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No246ZE0500XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherEEGGroup - Multi-Specialty