Provider Demographics
NPI:1588056139
Name:LIFELONG GOOD HEALTH LLC
Entity type:Organization
Organization Name:LIFELONG GOOD HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN NUTRITIONIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:LUCIA
Authorized Official - Middle Name:ISAC
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:RDN
Authorized Official - Phone:703-389-6612
Mailing Address - Street 1:14904 JEFFERSON DAVIS HWY
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22191-3908
Mailing Address - Country:US
Mailing Address - Phone:703-389-6612
Mailing Address - Fax:
Practice Address - Street 1:5721 RHODE ISALND DRIVE
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22193
Practice Address - Country:US
Practice Address - Phone:703-389-6612
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-19
Last Update Date:2015-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCD1100000386261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center