Healthcare Provider Details

I. General information

NPI: 1588087050
Provider Name (Legal Business Name): LIFE UNIVERSITY HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2014
Last Update Date: 02/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 W REDONDO BEACH BLVD
GARDENA CA
90248-1612
US

IV. Provider business mailing address

555 W REDONDO BEACH BLVD
GARDENA CA
90248-1612
US

V. Phone/Fax

Practice location:
  • Phone: 310-323-9001
  • Fax: 310-756-0004
Mailing address:
  • Phone: 310-323-9001
  • Fax: 310-756-0004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License NumberAC8057
License Number StateCA

VIII. Authorized Official

Name: DR. DONG WOO PARK
Title or Position: DEAN
Credential:
Phone: 310-323-9001