Healthcare Provider Details

I. General information

NPI: 1770808578
Provider Name (Legal Business Name): THE LIFE CENTER COMPLEX, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2010
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1624 JESSUP ST
WILMINGTON DE
19802-4210
US

IV. Provider business mailing address

812 PHILADELPHIA PIKE STE F
WILMINGTON DE
19809-2371
US

V. Phone/Fax

Practice location:
  • Phone: 302-552-3574
  • Fax: 302-552-3561
Mailing address:
  • Phone: 302-407-5316
  • Fax: 302-552-3561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number71788
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateDE

VIII. Authorized Official

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