=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669934055
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A FRIEND FOR LIFE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2019
-----------------------------------------------------
Last Update Date | 03/10/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 928 FORT STOCKTON DR STE 205
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92103-1893
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-450-4686
-----------------------------------------------------
Fax | 619-450-4689
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 928 FORT STOCKTON DR STE 205
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92103-1893
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-450-4686
-----------------------------------------------------
Fax | 619-450-4689
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPERATING MEMBER
-----------------------------------------------------
Name | MR. DAVID WALLACE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 619-450-4686
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3747P1801X
-----------------------------------------------------
Taxonomy Name | Personal Care Attendant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------