Healthcare Provider Details

I. General information

NPI: 1710715800
Provider Name (Legal Business Name): THE LIFE CENTER COMPLEX, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 07/22/2024
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 EDGMONT AVE
CHESTER PA
19013-3962
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 Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: FORREST WATSON
Title or Position: CEO
Credential:
Phone: 302-407-5316