Provider Demographics
NPI:1699836635
Name:LIFE CARE MEDICAL CENTER
Entity Type:Organization
Organization Name:LIFE CARE MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:KRAUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:856-881-5800
Mailing Address - Street 1:601 N MAIN ST
Mailing Address - Street 2:PO BOX 900
Mailing Address - City:GLASSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08028-1637
Mailing Address - Country:US
Mailing Address - Phone:856-881-5800
Mailing Address - Fax:856-881-3511
Practice Address - Street 1:601 N MAIN ST
Practice Address - Street 2:
Practice Address - City:GLASSBORO
Practice Address - State:NJ
Practice Address - Zip Code:08028-1637
Practice Address - Country:US
Practice Address - Phone:856-881-5800
Practice Address - Fax:856-881-3511
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ448666Medicare ID - Type Unspecified