Provider Demographics
NPI:1942290903
Name:LIFE MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:LIFE MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUNG
Authorized Official - Middle Name:J
Authorized Official - Last Name:YOO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-913-1116
Mailing Address - Street 1:18897 COLIMA RD STE A
Mailing Address - Street 2:
Mailing Address - City:ROWLAND HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91748-2977
Mailing Address - Country:US
Mailing Address - Phone:626-913-1116
Mailing Address - Fax:626-913-1261
Practice Address - Street 1:18897 COLIMA RD STE A
Practice Address - Street 2:
Practice Address - City:ROWLAND HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91748-2977
Practice Address - Country:US
Practice Address - Phone:626-913-1116
Practice Address - Fax:626-913-1261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-21
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG78232174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0098190Medicaid
CAGR0098190Medicaid
CA9846036Medicare UPIN
CAG23814Medicare UPIN