MEDICARE: LIFE CARE 360, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1275153579
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE CARE 360, LLC

Provider Business Mailing Address
First Line	:	12914 BROADWAY AVE
Second Line	:
City	:	GARFIELD HEIGHTS
State	:	OH
Zip	:	44125-1859
Country	:	US
Telephone Number	:	216-848-9123
Fax Number	:

Provider Business Practice Location Address
First Line	:	12914 BROADWAY AVE
Second Line	:
City	:	GARFIELD HEIGHTS
State	:	OH
Zip	:	44125-1859
Country	:	US
Telephone Number	:	216-848-9123
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	KENYATTA VANCE-ANDERSON
Credential	:
Telephone Number	:	216-848-9123

Provider Enumeration Date	:	04/16/2020
Last Update Date	:	04/16/2020

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