Healthcare Provider Details

I. General information

NPI: 1770291841
Provider Name (Legal Business Name): LIFETASTIC LEARNING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2022
Last Update Date: 11/08/2022
Certification Date: 11/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 S AZUSA AVE STE B-18
WEST COVINA CA
91791-8001
US

IV. Provider business mailing address

1414 S AZUSA AVE STE B-18
WEST COVINA CA
91791-8001
US

V. Phone/Fax

Practice location:
  • Phone: 626-534-1967
  • Fax:
Mailing address:
  • Phone: 626-534-1967
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State

VIII. Authorized Official

Name: ALICE LEE
Title or Position: DIRECTOR
Credential: BCBA
Phone: 626-534-1967