Provider Demographics
NPI:1073114211
Name:LIFECARE SPECIALTY CLINIC, INC
Entity Type:Organization
Organization Name:LIFECARE SPECIALTY CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:ROCHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:954-388-5850
Mailing Address - Street 1:PO BOX 565338
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33256-5338
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3880 COCONUT CREEK PKWY STE 100
Practice Address - Street 2:
Practice Address - City:COCONUT CREEK
Practice Address - State:FL
Practice Address - Zip Code:33066-1643
Practice Address - Country:US
Practice Address - Phone:954-388-5850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-04
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty