Healthcare Provider Details

I. General information

NPI: 1982540084
Provider Name (Legal Business Name): LIFE LAB LA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2026
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3917 HURON AVE UNIT 2
CULVER CITY CA
90232-3820
US

IV. Provider business mailing address

3917 HURON AVE UNIT 2
CULVER CITY CA
90232-3820
US

V. Phone/Fax

Practice location:
  • Phone: 818-632-7513
  • Fax:
Mailing address:
  • Phone: 818-632-7513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: MAX ERIC BLUM
Title or Position: PRESIDENT
Credential: M.S, BCBA
Phone: 818-632-7513