Healthcare Provider Details

I. General information

NPI: 1609590538
Provider Name (Legal Business Name): THE LIFE CENTER COMPLEX, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2022
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

629 BUCKSON DR
DOVER DE
19901-2503
US

IV. Provider business mailing address

812 PHILADELPHIA PIKE STE F
WILMINGTON DE
19809-2371
US

V. Phone/Fax

Practice location:
  • Phone: 302-407-5316
  • Fax:
Mailing address:
  • Phone: 302-407-5316
  • Fax:

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