Healthcare Provider Details

I. General information

NPI: 1164315040
Provider Name (Legal Business Name): THE LIFE CENTER COMPLEX, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2025
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3707 N MARKET ST
WILMINGTON DE
19802-2213
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 TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. KIM PURNELL
Title or Position: OPERATIONS COORDINATOR
Credential:
Phone: 302-407-5316