Healthcare Provider Details

I. General information

NPI: 1790097145
Provider Name (Legal Business Name): LIFELINE WOUND CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2010
Last Update Date: 07/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22361 PACIFIC COAST HWY STE 441
MALIBU CA
90265
US

IV. Provider business mailing address

20301 VENTURA BLVD SUITE 115
WOODLAND HILLS CA
91364-2447
US

V. Phone/Fax

Practice location:
  • Phone: 818-992-1801
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberG29768
License Number StateCA

VIII. Authorized Official

Name: DR. STEVEN KAYE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 310-871-3434