=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629114723
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CROWN OF LIFE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/29/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14644 LAKEWOOD AVE
-----------------------------------------------------
City | JAMAICA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11435-5438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-526-8921
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14644 LAKEWOOD AVE
-----------------------------------------------------
City | JAMAICA
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11435-5438
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-526-8921
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE PROPRIETOR
-----------------------------------------------------
Name | RANDY ANGLIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-526-8921
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 1180L001
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------