Provider Demographics
NPI:1598188849
Name:LIFE ENHANCEMENT MEDICINE AND REHABILITATION, P.A.
Entity type:Organization
Organization Name:LIFE ENHANCEMENT MEDICINE AND REHABILITATION, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BULLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:785-856-5440
Mailing Address - Street 1:3001 CARRINGTON LN
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66049-1732
Mailing Address - Country:US
Mailing Address - Phone:785-856-5440
Mailing Address - Fax:785-856-5441
Practice Address - Street 1:3001 CARRINGTON LN
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66049-1732
Practice Address - Country:US
Practice Address - Phone:785-856-5440
Practice Address - Fax:785-856-5441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-22
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0531368204D00000X, 208VP0000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty