Provider Demographics
NPI:1669012993
Name:THE LIFE CENTER COMPLEX, INC
Entity Type:Organization
Organization Name:THE LIFE CENTER COMPLEX, INC
Other - Org Name:THE LIFE HEALTH CENTER @ BANCROFT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:FORREST
Authorized Official - Middle Name:
Authorized Official - Last Name:WATSON
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:302-407-5316
Mailing Address - Street 1:812 PHILADELPHIA PIKE STE F
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19809-2371
Mailing Address - Country:US
Mailing Address - Phone:302-407-5316
Mailing Address - Fax:302-429-3956
Practice Address - Street 1:700 N LOMBARD ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19801-4217
Practice Address - Country:US
Practice Address - Phone:302-429-4102
Practice Address - Fax:302-429-3956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-15
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health