Provider Demographics
NPI:1376869073
Name:LIFE EXTENSION CLINICS, INC
Entity Type:Organization
Organization Name:LIFE EXTENSION CLINICS, INC
Other - Org Name:LIFE SCAN WELLNESS CENTERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-876-0625
Mailing Address - Street 1:1011 N MACDILL AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-5126
Mailing Address - Country:US
Mailing Address - Phone:813-876-0625
Mailing Address - Fax:813-876-0653
Practice Address - Street 1:1011 N MACDILL AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-5126
Practice Address - Country:US
Practice Address - Phone:813-876-0625
Practice Address - Fax:813-876-0653
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-20
Last Update Date:2010-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN1456802163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Single Specialty