Provider Demographics
NPI:1306240049
Name:MARSHALL LIFESTYLE MEDICINE, PSC
Entity type:Organization
Organization Name:MARSHALL LIFESTYLE MEDICINE, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KITCHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-608-4841
Mailing Address - Street 1:2105 WICKSBURY PL
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-1168
Mailing Address - Country:US
Mailing Address - Phone:859-608-4841
Mailing Address - Fax:
Practice Address - Street 1:2251 WAR ADMIRAL WAY
Practice Address - Street 2:SUITE 125
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-2546
Practice Address - Country:US
Practice Address - Phone:859-608-4841
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-09
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty