Provider Demographics
NPI:1235831611
Name:LIFESHADES OF NURSING PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:LIFESHADES OF NURSING PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAYNA
Authorized Official - Middle Name:
Authorized Official - Last Name:CVETKOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-641-4250
Mailing Address - Street 1:2305 HISTORIC DECATUR RD STE 186
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92106-6071
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2305 HISTORIC DECATUR RD STE 186
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-6071
Practice Address - Country:US
Practice Address - Phone:818-641-4250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty