Basic Information
| Provider Information | |||||||||
| NPI: | 1033228648 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIFEWORKS WELLNESS CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 301 TURNER ST. | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337565326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7274666789 | ||||||||
| FaxNumber: | 7274511010 | ||||||||
| Practice Location | |||||||||
| Address1: | 301 TURNER ST | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337565326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7274666789 | ||||||||
| FaxNumber: | 7274511010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 08/25/2011 | ||||||||
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| AuthorizedOfficialLastName: | MINKOFF | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | I | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7274666789 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 33369 | 01 | FL | BLUE CROSS/BLUE SHIELD | OTHER |