Provider Demographics
NPI:1881028892
Name:DOCTOR FOR LIFE, LLC
Entity Type:Organization
Organization Name:DOCTOR FOR LIFE, LLC
Other - Org Name:DR. FOR LIFE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-202-7033
Mailing Address - Street 1:2131 WOODRUFF ROAD
Mailing Address - Street 2:SUITE 2100 #127
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-5959
Mailing Address - Country:US
Mailing Address - Phone:864-640-0009
Mailing Address - Fax:864-558-0589
Practice Address - Street 1:1202 E BUTLER RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-5910
Practice Address - Country:US
Practice Address - Phone:864-640-0009
Practice Address - Fax:864-558-0589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-27
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP6250Medicaid