Provider Demographics
NPI:1861278467
Name:THE LIFESTYLE CLINIC LLC
Entity type:Organization
Organization Name:THE LIFESTYLE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ACUPUNCTURE PHYSCIAN - OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDERSON
Authorized Official - Middle Name:CARLOS
Authorized Official - Last Name:GONCALVES
Authorized Official - Suffix:
Authorized Official - Credentials:LAC, DACM
Authorized Official - Phone:352-693-2681
Mailing Address - Street 1:10935 SE 177TH PL STE 201
Mailing Address - Street 2:
Mailing Address - City:SUMMERFIELD
Mailing Address - State:FL
Mailing Address - Zip Code:34491-8971
Mailing Address - Country:US
Mailing Address - Phone:352-693-2681
Mailing Address - Fax:
Practice Address - Street 1:10935 SE 177TH PL STE 201
Practice Address - Street 2:
Practice Address - City:SUMMERFIELD
Practice Address - State:FL
Practice Address - Zip Code:34491-8971
Practice Address - Country:US
Practice Address - Phone:352-693-2681
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty