Provider Demographics
NPI:1316970296
Name:LIFESTREAM, INC.
Entity type:Organization
Organization Name:LIFESTREAM, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DOVI
Authorized Official - Middle Name:
Authorized Official - Last Name:FAIVISH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-264-2021
Mailing Address - Street 1:2471 NW 72ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33122-1829
Mailing Address - Country:US
Mailing Address - Phone:305-264-2021
Mailing Address - Fax:305-265-0755
Practice Address - Street 1:3350 SW 148TH AVE STE 202-B
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-3257
Practice Address - Country:US
Practice Address - Phone:305-264-2021
Practice Address - Fax:305-265-0755
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
335V00000X
FLHCC6414293D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU7017Medicare PIN
FLU7010Medicare UPIN