Healthcare Provider Details

I. General information

NPI: 1083799357
Provider Name (Legal Business Name): LIFE MEDICAL CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 08/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 TROY TOWN DR
TROY OH
45373-2328
US

IV. Provider business mailing address

PO BOX 4428
SIDNEY OH
45365-4428
US

V. Phone/Fax

Practice location:
  • Phone: 937-681-5740
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35067724
License Number StateOH

VIII. Authorized Official

Name: MRS. JULIE RENEE GRAWE
Title or Position: BILLING SPECIALIST
Credential:
Phone: 937-681-5740