Healthcare Provider Details

I. General information

NPI: 1295405140
Provider Name (Legal Business Name): THE LIFE CHARM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2021
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1419 UNIVERSITY AVE
SAN DIEGO CA
92103-3459
US

IV. Provider business mailing address

6231 VISTA SAN CARLOS
SAN DIEGO CA
92154-5607
US

V. Phone/Fax

Practice location:
  • Phone: 619-876-4015
  • Fax: 619-883-9360
Mailing address:
  • Phone: 619-876-4015
  • Fax: 619-883-9360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TYLER PENROD
Title or Position: BILLER
Credential:
Phone: 305-900-4715