Lifelong Wellness Clinic PLLC

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

N2319 Issued in TX

Legal business name

LIFELONG WELLNESS CLINIC PLLC

Practice address

711 W Main St
Eastland, TX 76448-2534

Phone

(254) 629-1100

Fax

(254) 629-1104

NPI assigned

Jul 28, 2011

Last updated

Oct 23, 2013By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Christopher Tidroski, D.O.NPI 1144459868

Title

Owner

Phone

(254) 629-1100

Specialties & licenses 2

Addresses

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Christopher Tidroski, D.O.

  • Family Medicine Physician
  • Eastland, TX
  • NPI 1144459868
  NPD (past) Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1311811200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1382486400000",
    "number": "1114205812",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "711 W MAIN ST",
            "city": "EASTLAND",
            "state": "TX",
            "postal_code": "764482534",
            "telephone_number": "254-629-1100",
            "fax_number": "254-629-1104"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "711 W MAIN ST",
            "city": "EASTLAND",
            "state": "TX",
            "postal_code": "764482534",
            "telephone_number": "254-629-1100",
            "fax_number": "254-629-1104"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LIFELONG WELLNESS CLINIC PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-07-28",
        "last_updated": "2013-10-23",
        "status": "A",
        "authorized_official_last_name": "TIDROSKI",
        "authorized_official_first_name": "CHRISTOPHER",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "254-629-1100",
        "authorized_official_credential": "D.O."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": "TX",
            "license": "N2319",
            "primary": true
        },
        {
            "code": "208000000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics",
            "state": "TX",
            "license": "P0309",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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• Family Medicine Physician in Eastland, TX
• Providers in Eastland, TX by specialty
• Family Medicine Physician in Texas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 23, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.