Provider Demographics
NPI:1841960937
Name:LIFEHOPE TRIF3CTA SPORTS MEDICINE, LLC
Entity type:Organization
Organization Name:LIFEHOPE TRIF3CTA SPORTS MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAESON
Authorized Official - Middle Name:
Authorized Official - Last Name:COURSEAULT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-982-7141
Mailing Address - Street 1:11680 GREAT OAKS WAY
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-2457
Mailing Address - Country:US
Mailing Address - Phone:404-500-7224
Mailing Address - Fax:
Practice Address - Street 1:11680 GREAT OAKS WAY
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-2457
Practice Address - Country:US
Practice Address - Phone:404-500-7224
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-20
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Multi-Specialty