=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447504147
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFESPAN THE CENTER FOR AGING AND REGENERATIVE MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2012
-----------------------------------------------------
Last Update Date | 12/03/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1465 VICTOR AVE SUITE A
-----------------------------------------------------
City | REDDING
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96003-4856
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-605-4557
-----------------------------------------------------
Fax | 530-605-4531
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 496084
-----------------------------------------------------
City | REDDING
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 96049-6084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-605-4557
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DANIEL GOODMAN
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 530-605-4557
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | G63650
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------