Provider Demographics
NPI:1366840506
Name:LIFE MEDICAL GROUP
Entity Type:Organization
Organization Name:LIFE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:LUIS
Authorized Official - Last Name:ROCAFORT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:787-361-3580
Mailing Address - Street 1:PO BOX 360402
Mailing Address - Street 2:SAN JUAN STATION
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00936-0402
Mailing Address - Country:US
Mailing Address - Phone:787-275-1859
Mailing Address - Fax:
Practice Address - Street 1:76 CALLE LAS FLORES
Practice Address - Street 2:
Practice Address - City:CATANO
Practice Address - State:PR
Practice Address - Zip Code:00962-4744
Practice Address - Country:US
Practice Address - Phone:787-275-1859
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-19
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR16002261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service