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General NPI Number Information
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NPI Number | 1497575740
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Entity Type | Organization
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Legal Business Name | THE LIFE CENTER COMPLEX, INC
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Dates
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Enumeration Date | 10/11/2024
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Last Update Date | 10/11/2024
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Provider Practice Location Address
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Address Line | 2814 W 2ND ST
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City | WILMINGTON
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State | DE
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Zip | 19805-1807
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Country | US
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Telephone | 302-407-5316
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Fax |
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Provider Business Mailing Address
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Address Line | 812 PHILADELPHIA PIKE STE F
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City | WILMINGTON
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State | DE
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Zip | 19809-2371
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Country | US
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Telephone | 302-407-5316
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MR. FORREST WATSON
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Credential |
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Telephone | 302-407-5316
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 2083P0901X
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Taxonomy Name | Public Health & General Preventive Medicine Physician
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 261QS1000X
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Taxonomy Name | Student Health Clinic/Center
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License Number |
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License Number State |
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