MEDICARE: LIFE SHAPE CENTER 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	106H00000X	Marriage & Family Therapist
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1831573740
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE SHAPE CENTER LLC

Provider Business Mailing Address
First Line	:	PO BOX 30004
Second Line	:
City	:	PALM BEACH GARDENS
State	:	FL
Zip	:	33420-0004
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2575 LONE PINE RD
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33410-2447
Country	:	US
Telephone Number	:	561-379-4337
Fax Number	:

Authorized Official
Title or Position	:	OWNER/MANAGER
Name	:	CRAIG KERNS
Credential	:
Telephone Number	:	561-379-4337

Provider Enumeration Date	:	07/10/2015
Last Update Date	:	07/10/2015

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Directions to “LIFE SHAPE CENTER LLC ” Practice Location

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