Healthcare Provider Details

I. General information

NPI: 1053059378
Provider Name (Legal Business Name): LIFESTYLE BOARD AND CARE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2022
Last Update Date: 05/25/2022
Certification Date: 05/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

149 E 235TH ST
CARSON CA
90745-5318
US

IV. Provider business mailing address

149 E 235TH ST
CARSON CA
90745-5318
US

V. Phone/Fax

Practice location:
  • Phone: 310-834-9325
  • Fax:
Mailing address:
  • Phone: 310-834-9325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM GALLIOS
Title or Position: OFFICE MANAGER
Credential:
Phone: 702-290-3235