Healthcare Provider Details

I. General information

NPI: 1639821648
Provider Name (Legal Business Name): LIFE LINE CORPORATION -4 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/20/2022
Last Update Date: 09/10/2025
Certification Date: 09/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

349 MALCOLM DR
WESTMINSTER MD
21157-6106
US

IV. Provider business mailing address

1798 ODEN WAY
ELDERSBURG MD
21784-7095
US

V. Phone/Fax

Practice location:
  • Phone: 410-848-2566
  • Fax:
Mailing address:
  • Phone: 443-255-3951
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State

VIII. Authorized Official

Name: KAMAL G. BANGORIA
Title or Position: PRESIDENT
Credential: MD
Phone: 443-255-3951