MEDICARE: LIFE EXTENSION CLINICS, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WG0000X	General Practice Registered Nurse	RN1456802	FL

General Provider Information

NPI Number	:	1376869073
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE EXTENSION CLINICS, INC

Provider Business Mailing Address
First Line	:	1011 N MACDILL AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607-5126
Country	:	US
Telephone Number	:	813-876-0625
Fax Number	:	813-876-0653

Provider Business Practice Location Address
First Line	:	1011 N MACDILL AVE
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33607-5126
Country	:	US
Telephone Number	:	813-876-0625
Fax Number	:	813-876-0653

Authorized Official
Title or Position	:	CEO
Name	:	PATRICIA JOHNSON
Credential	:
Telephone Number	:	813-876-0625

Provider Enumeration Date	:	04/20/2010
Last Update Date	:	04/20/2010

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