Healthcare Provider Details

I. General information

NPI: 1467134916
Provider Name (Legal Business Name): GREAT LIFE SENIOR CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2023
Last Update Date: 08/03/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29158 SHADOW HILLS ST
MENIFEE CA
92584-7671
US

IV. Provider business mailing address

29158 SHADOW HILLS ST
MENIFEE CA
92584-7671
US

V. Phone/Fax

Practice location:
  • Phone: 951-679-9592
  • Fax:
Mailing address:
  • Phone: 951-679-9592
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. JASON ELLIOT WHITE
Title or Position: CEO
Credential:
Phone: 951-679-9592