Provider Demographics
NPI:1033519657
Name:LIFE LINE COMMUNITY HEALTHCARE CALIFORNIA
Entity Type:Organization
Organization Name:LIFE LINE COMMUNITY HEALTHCARE CALIFORNIA
Other - Org Name:LIFE LINE COMMUNITY HEALTHCARE-CA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:J
Authorized Official - Last Name:MANGANARO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-581-6556
Mailing Address - Street 1:6150 OAK TREE BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131-2569
Mailing Address - Country:US
Mailing Address - Phone:216-581-6556
Mailing Address - Fax:216-581-9611
Practice Address - Street 1:5042 WILSHIRE BLVD # 14249
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90036-4305
Practice Address - Country:US
Practice Address - Phone:216-581-6556
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-02
Last Update Date:2014-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA332592083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Single Specialty