Provider Demographics
NPI:1780178764
Name:LIFESPRING LABORATORIES
Entity type:Organization
Organization Name:LIFESPRING LABORATORIES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-561-3037
Mailing Address - Street 1:1415 HIGHWAY 85 N STE 310-406
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-7738
Mailing Address - Country:US
Mailing Address - Phone:678-561-3037
Mailing Address - Fax:667-260-6180
Practice Address - Street 1:2200 GARRISON BLVD STE 3013
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21216
Practice Address - Country:US
Practice Address - Phone:678-561-2140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-21
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21D2149021291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory