=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245607589
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE MD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2015
-----------------------------------------------------
Last Update Date | 08/21/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1901 S CONGRESS AVE SUITE 150
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33426-6556
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-954-8281
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12718 OAK RUN CT
-----------------------------------------------------
City | BOYNTON BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33436-6134
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-954-8281
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MARK L VOLLARO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 866-954-8281
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------