MEDICARE: A FRIEND FOR LIFE LLC

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	3747P1801X	Personal Care Attendant
2	253Z00000X	In Home Supportive Care Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	374700018	OTHER	CA	STATE OF CALIFORNIA HOME CARE SERVICES BUREAU

General Provider Information

NPI Number	:	1669934055
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A FRIEND FOR LIFE LLC

Provider Business Mailing Address
First Line	:	928 FORT STOCKTON DR STE 205
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-1893
Country	:	US
Telephone Number	:	619-450-4686
Fax Number	:	619-450-4689

Provider Business Practice Location Address
First Line	:	928 FORT STOCKTON DR STE 205
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-1893
Country	:	US
Telephone Number	:	619-450-4686
Fax Number	:	619-450-4689

Authorized Official
Title or Position	:	OPERATING MEMBER
Name	:	MR. DAVID WALLACE
Credential	:
Telephone Number	:	619-450-4686

Provider Enumeration Date	:	04/03/2019
Last Update Date	:	03/10/2021

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Directions to “A FRIEND FOR LIFE LLC ” Practice Location

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