Healthcare Provider Details

I. General information

NPI: 1235831611
Provider Name (Legal Business Name): LIFESHADES OF NURSING PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 03/20/2023
Certification Date: 03/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2305 HISTORIC DECATUR RD STE 186
SAN DIEGO CA
92106-6071
US

IV. Provider business mailing address

2305 HISTORIC DECATUR RD STE 186
SAN DIEGO CA
92106-6071
US

V. Phone/Fax

Practice location:
  • Phone: 818-641-4250
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: RAYNA CVETKOVA
Title or Position: OWNER
Credential:
Phone: 818-641-4250