Provider Demographics
NPI:1831951979
Name:LIFESTYLE COMMUNITY CLINIC A NONPROFIT CORPORATION
Entity type:Organization
Organization Name:LIFESTYLE COMMUNITY CLINIC A NONPROFIT CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ESTHER
Authorized Official - Middle Name:M
Authorized Official - Last Name:PARK HWANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-732-3573
Mailing Address - Street 1:4545 S UNION AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98409-4532
Mailing Address - Country:US
Mailing Address - Phone:253-732-3573
Mailing Address - Fax:
Practice Address - Street 1:4545 S UNION AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98409-4532
Practice Address - Country:US
Practice Address - Phone:253-732-3573
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-24
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No251V00000XAgenciesVoluntary or CharitableGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QB0400XAmbulatory Health Care FacilitiesClinic/CenterBirthing
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No333600000XSuppliersPharmacy