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General NPI Number Information
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NPI Number | 1275153579
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Entity Type | Organization
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Legal Business Name | LIFE CARE 360, LLC
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Dates
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Enumeration Date | 04/16/2020
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Last Update Date | 04/16/2020
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Provider Practice Location Address
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Address Line | 12914 BROADWAY AVE
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City | GARFIELD HEIGHTS
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State | OH
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Zip | 44125-1859
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Country | US
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Telephone | 216-848-9123
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Fax |
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Provider Business Mailing Address
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Address Line | 12914 BROADWAY AVE
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City | GARFIELD HEIGHTS
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State | OH
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Zip | 44125-1859
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Country | US
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Telephone | 216-848-9123
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | KENYATTA VANCE-ANDERSON
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Credential |
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Telephone | 216-848-9123
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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