Provider Demographics
NPI:1215496450
Name:LIFETIME BODY AND HEALTH AWARENESS HAYNES PHYSICAL THERAPY
Entity type:Organization
Organization Name:LIFETIME BODY AND HEALTH AWARENESS HAYNES PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHENITA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:DPT,CEEAA
Authorized Official - Phone:702-831-8076
Mailing Address - Street 1:5516 BOULDER HWY
Mailing Address - Street 2:STE. 2-F # 279
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89122
Mailing Address - Country:US
Mailing Address - Phone:702-831-8076
Mailing Address - Fax:
Practice Address - Street 1:10825 VESTONE ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89141-0481
Practice Address - Country:US
Practice Address - Phone:702-831-8076
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-18
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty