Provider Demographics
NPI:1639821648
Name:LIFE LINE CORPORATION -4 LLC
Entity Type:Organization
Organization Name:LIFE LINE CORPORATION -4 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KAMAL
Authorized Official - Middle Name:G
Authorized Official - Last Name:BANGORIA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:443-255-3951
Mailing Address - Street 1:1798 ODEN WAY
Mailing Address - Street 2:
Mailing Address - City:ELDERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:21784-7095
Mailing Address - Country:US
Mailing Address - Phone:443-255-3951
Mailing Address - Fax:
Practice Address - Street 1:349 MALCOLM DR
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:MD
Practice Address - Zip Code:21157-6106
Practice Address - Country:US
Practice Address - Phone:410-848-2566
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty