Provider Demographics
NPI:1336527845
Name:LIFESPAN HEALTHCARE
Entity type:Organization
Organization Name:LIFESPAN HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRIMARY CARE PROVIDER / OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANARESIA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:RICHARD
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:480-633-3540
Mailing Address - Street 1:690 E WARNER RD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-3054
Mailing Address - Country:US
Mailing Address - Phone:480-633-3540
Mailing Address - Fax:480-633-5605
Practice Address - Street 1:690 E WARNER RD
Practice Address - Street 2:112
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-3054
Practice Address - Country:US
Practice Address - Phone:480-633-3540
Practice Address - Fax:480-633-5605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-16
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP1692261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ766777Medicaid
P83975Medicare UPIN