=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245489384
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE CONNECT MEDICAL, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2008
-----------------------------------------------------
Last Update Date | 05/03/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 35900 BOB HOPE DR SUITE # 100
-----------------------------------------------------
City | RANCHO MIRAGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92270-1766
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-699-7117
-----------------------------------------------------
Fax | 760-699-7750
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 36101 BOB HOPE DR STE. E-5 #117
-----------------------------------------------------
City | RANCHO MIRAGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92270-2001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-217-0126
-----------------------------------------------------
Fax | 760-699-7750
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. PADMA KHANCHUSTAMBAHM
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 760-464-2166
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | A86478
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------