=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629233523
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFEWAY HEALTHCARE SERVICES INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2008
-----------------------------------------------------
Last Update Date | 07/21/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10024 S VERMONT AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90044-3112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-242-3888
-----------------------------------------------------
Fax | 323-242-1188
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10024 S VERMONT AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90044-3112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-242-3888
-----------------------------------------------------
Fax | 323-242-1188
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | DR. KINGSLEY O OFOEGBU
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 323-242-3888
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | A73040
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------