Provider Demographics
NPI:1790587269
Name:LIFESTYLE PROVIDERS
Entity type:Organization
Organization Name:LIFESTYLE PROVIDERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUPERIA
Authorized Official - Middle Name:
Authorized Official - Last Name:INGALLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-287-1546
Mailing Address - Street 1:821 COURTNEY WAY
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-6330
Mailing Address - Country:US
Mailing Address - Phone:856-287-1546
Mailing Address - Fax:
Practice Address - Street 1:821 COURTNEY WAY
Practice Address - Street 2:
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-6330
Practice Address - Country:US
Practice Address - Phone:856-287-1546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-26
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies