MEDICARE: LIFE SERVICE PROFESSIONAL CORP

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	174400000X	Specialist		IN

General Provider Information

NPI Number	:	1659484053
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE SERVICE PROFESSIONAL CORP

Provider Business Mailing Address
First Line	:	1015 N SHELBY ST
Second Line	:
City	:	GARY
State	:	IN
Zip	:	46403-1446
Country	:	US
Telephone Number	:	219-938-0920
Fax Number	:	219-938-0923

Provider Business Practice Location Address
First Line	:	1015 N SHELBY ST
Second Line	:
City	:	GARY
State	:	IN
Zip	:	46403-1446
Country	:	US
Telephone Number	:	219-938-0920
Fax Number	:	219-938-0923

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. GERALDINE BARRON-SIMPSON
Credential	:
Telephone Number	:	219-938-0920

Provider Enumeration Date	:	08/17/2006
Last Update Date	:	07/21/2022

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Directions to “LIFE SERVICE PROFESSIONAL CORP ” Practice Location

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