Provider Demographics
NPI:1881728996
Name:LIFESTREAM HEALTH CENTER
Entity type:Organization
Organization Name:LIFESTREAM HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MERRITT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-860-0305
Mailing Address - Street 1:4000 MITCHELLVILLE RD
Mailing Address - Street 2:SUITE B322
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20716
Mailing Address - Country:US
Mailing Address - Phone:301-860-0305
Mailing Address - Fax:301-860-0307
Practice Address - Street 1:4000 MITCHELLVILLE RD
Practice Address - Street 2:SUITE B322
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20716
Practice Address - Country:US
Practice Address - Phone:301-860-0305
Practice Address - Fax:301-860-0307
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0029051174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
B93531Medicare UPIN