Provider Demographics
NPI:1043536592
Name:LIFESPAN MEDICINE
Entity Type:Organization
Organization Name:LIFESPAN MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:RENNE
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:310-453-2335
Mailing Address - Street 1:2811 WILSHIRE BLVD
Mailing Address - Street 2:#610
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403
Mailing Address - Country:US
Mailing Address - Phone:310-453-2335
Mailing Address - Fax:310-453-2332
Practice Address - Street 1:2811 WILSHIRE BLVD
Practice Address - Street 2:SUITE 610
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403
Practice Address - Country:US
Practice Address - Phone:310-453-2335
Practice Address - Fax:310-453-2332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-08
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty