Provider Demographics
NPI:1477894202
Name:LIFE CENTERS OF AMERICA LLC
Entity Type:Organization
Organization Name:LIFE CENTERS OF AMERICA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE - PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSIAH
Authorized Official - Middle Name:MALIK
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-473-8876
Mailing Address - Street 1:8509 HARFORD RD
Mailing Address - Street 2:
Mailing Address - City:PARKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21234-4619
Mailing Address - Country:US
Mailing Address - Phone:410-497-4514
Mailing Address - Fax:
Practice Address - Street 1:8509 HARFORD RD
Practice Address - Street 2:
Practice Address - City:PARKVILLE
Practice Address - State:MD
Practice Address - Zip Code:21234
Practice Address - Country:US
Practice Address - Phone:443-819-6350
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-04
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty