Healthcare Provider Details

I. General information

NPI: 1225614506
Provider Name (Legal Business Name): LIFE LEARNING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2021
Last Update Date: 03/18/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 BRANDYWINE BLVD
WILMINGTON DE
19809-3235
US

IV. Provider business mailing address

5 BRANDYWINE BLVD
WILMINGTON DE
19809-3235
US

V. Phone/Fax

Practice location:
  • Phone: 302-300-5519
  • Fax: 302-552-3561
Mailing address:
  • Phone: 302-300-5519
  • Fax: 302-552-3561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: FORREST WATSON IV
Title or Position: CEO
Credential:
Phone: 302-300-5519