Healthcare Provider Details

I. General information

NPI: 1912545518
Provider Name (Legal Business Name): THE LIFE CENTER COMPLEX, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2019
Last Update Date: 12/13/2019
Certification Date: 12/13/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 CHASE AVE
NEW CASTLE DE
19720-1236
US

IV. Provider business mailing address

222 PHILADELPHIA PIKE STE 13
WILMINGTON DE
19809-3166
US

V. Phone/Fax

Practice location:
  • Phone: 302-429-4000
  • Fax:
Mailing address:
  • Phone: 302-407-5316
  • Fax: 302-407-5307

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: MR. FORREST WATSON III
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 302-407-5316