Provider Demographics
NPI:1629233523
Name:LIFEWAY HEALTHCARE SERVICES INC.
Entity Type:Organization
Organization Name:LIFEWAY HEALTHCARE SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KINGSLEY
Authorized Official - Middle Name:O
Authorized Official - Last Name:OFOEGBU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-242-3888
Mailing Address - Street 1:10024 S VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90044-3112
Mailing Address - Country:US
Mailing Address - Phone:323-242-3888
Mailing Address - Fax:323-242-1188
Practice Address - Street 1:10024 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90044-3112
Practice Address - Country:US
Practice Address - Phone:323-242-3888
Practice Address - Fax:323-242-1188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-21
Last Update Date:2008-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73040207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A730400Medicaid
CA1285732354OtherNPI