Healthcare Provider Details

I. General information

NPI: 1467939082
Provider Name (Legal Business Name): THE LIFE CENTER COMPLEX, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2018
Last Update Date: 07/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 LANDERS LN
NEW CASTLE DE
19720-2022
US

IV. Provider business mailing address

222 PHILADELPHIA PIKE STE 13-15
WILMINGTON DE
19809-3166
US

V. Phone/Fax

Practice location:
  • Phone: 302-429-4083
  • Fax: 302-429-4078
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 StateDE

VIII. Authorized Official

Name: MR. FORREST WATSON III
Title or Position: CEO
Credential: MBA
Phone: 302-552-3574