Provider Demographics
NPI:1114496809
Name:LIFE ACUMED SPA
Entity Type:Organization
Organization Name:LIFE ACUMED SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:JEONG
Authorized Official - Suffix:
Authorized Official - Credentials:DAOM
Authorized Official - Phone:650-458-3391
Mailing Address - Street 1:146 W 25TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94403-2208
Mailing Address - Country:US
Mailing Address - Phone:650-458-3391
Mailing Address - Fax:
Practice Address - Street 1:146 W 25TH AVE.
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-2208
Practice Address - Country:US
Practice Address - Phone:650-458-3391
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFE ACUMED SPA INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA46-2930319OtherNPI