Provider Demographics
NPI:1114996832
Name:LIFE-LIKE LABORATORY LLC
Entity Type:Organization
Organization Name:LIFE-LIKE LABORATORY LLC
Other - Org Name:LIFE-LIKE LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:FANCHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-620-0203
Mailing Address - Street 1:1548 VALWOOD PKWY STE 108
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:TX
Mailing Address - Zip Code:75006-6859
Mailing Address - Country:US
Mailing Address - Phone:972-620-0203
Mailing Address - Fax:972-620-0204
Practice Address - Street 1:1548 VALWOOD PKWY STE 108
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:TX
Practice Address - Zip Code:75006-6859
Practice Address - Country:US
Practice Address - Phone:972-620-0203
Practice Address - Fax:972-620-0204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-15
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
335E00000X
TX101286335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX507603OtherBCBS
TX0537960001Medicare ID - Type UnspecifiedMEDICARE NUMBER