Provider Demographics
NPI:1801512819
Name:FIRST LIGHT LIFESTYLE MEDICAL CLINIC PLLC
Entity type:Organization
Organization Name:FIRST LIGHT LIFESTYLE MEDICAL CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VOLNEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLETT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:701-483-6974
Mailing Address - Street 1:30 7TH ST W STE LL-50
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-4335
Mailing Address - Country:US
Mailing Address - Phone:701-483-6974
Mailing Address - Fax:
Practice Address - Street 1:30 7TH ST W STE LL-50
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-4335
Practice Address - Country:US
Practice Address - Phone:701-483-6974
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-12
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty