Healthcare Provider Details

I. General information

NPI: 1174004345
Provider Name (Legal Business Name): THE LIFE CENTER COMPLEX, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2018
Last Update Date: 08/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4050 WRANGLE HILL RD
BEAR DE
19701
US

IV. Provider business mailing address

222 PHILADELPHIA PIKE STE 13
WILMINGTON DE
19809-3166
US

V. Phone/Fax

Practice location:
  • Phone: 302-552-3574
  • Fax: 302-552-3561
Mailing address:
  • Phone: 302-552-3574
  • Fax: 302-552-3561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: FORREST WATSON
Title or Position: CEO
Credential:
Phone: 302-552-3574