Provider Demographics
NPI:1386613180
Name:LIFE MEDICAL CENTER OF LECANTO,INC
Entity type:Organization
Organization Name:LIFE MEDICAL CENTER OF LECANTO,INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:S
Authorized Official - Last Name:KINNARD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:352-726-0554
Mailing Address - Street 1:2611 HIGHWAY 44 W
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34453-3725
Mailing Address - Country:US
Mailing Address - Phone:352-726-0554
Mailing Address - Fax:352-726-3885
Practice Address - Street 1:2611 HIGHWAY 44 W
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34453-3725
Practice Address - Country:US
Practice Address - Phone:352-726-0554
Practice Address - Fax:352-726-3885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH6693111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
38954OtherBLUE CROSS & BLUE SHIELD
FLK0394Medicare PIN