Provider Demographics
NPI:1912545518
Name:THE LIFE CENTER COMPLEX, INC.
Entity Type:Organization
Organization Name:THE LIFE CENTER COMPLEX, INC.
Other - Org Name:
Other - Org Type:
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 1:222 PHILADELPHIA PIKE STE 13
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19809-3166
Mailing Address - Country:US
Mailing Address - Phone:302-407-5316
Mailing Address - Fax:302-407-5307
Practice Address - Street 1:20 CHASE AVE
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:DE
Practice Address - Zip Code:19720-1236
Practice Address - Country:US
Practice Address - Phone:302-429-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-13
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health