Provider Demographics
NPI:1396190831
Name:IANNOTTI LIFESTYLE CLINIC PC
Entity type:Organization
Organization Name:IANNOTTI LIFESTYLE CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:IANNOTTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:720-773-1352
Mailing Address - Street 1:150 OLD LARAMIE TRL E
Mailing Address - Street 2:SUITE 210
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-7018
Mailing Address - Country:US
Mailing Address - Phone:720-773-1352
Mailing Address - Fax:303-604-6958
Practice Address - Street 1:150 OLD LARAMIE TRL E
Practice Address - Street 2:SUITE 210
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-7018
Practice Address - Country:US
Practice Address - Phone:720-773-1352
Practice Address - Fax:303-604-6958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-03
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0039567207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty