Healthcare Provider Details

I. General information

NPI: 1033586698
Provider Name (Legal Business Name): LIFE UNCOMMON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2015
Last Update Date: 10/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8616 LA TIJERA BLVD SUITE 404
LOS ANGELES CA
90045-3944
US

IV. Provider business mailing address

8616 LA TIJERA BLVD SUITE 404
LOS ANGELES CA
90045-3944
US

V. Phone/Fax

Practice location:
  • Phone: 310-356-9951
  • Fax:
Mailing address:
  • Phone: 310-356-9951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. CORRIE L GREATHOUSE
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 310-356-9951