Provider Demographics
NPI:1184906547
Name:LIFE MEDICAL CENTER INC.
Entity type:Organization
Organization Name:LIFE MEDICAL CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KHAI
Authorized Official - Middle Name:QUANG
Authorized Official - Last Name:TRAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:909-395-9888
Mailing Address - Street 1:653 E E ST
Mailing Address - Street 2:SUITE 108
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-4257
Mailing Address - Country:US
Mailing Address - Phone:909-395-9888
Mailing Address - Fax:
Practice Address - Street 1:653 E E ST
Practice Address - Street 2:SUITE 108
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-4257
Practice Address - Country:US
Practice Address - Phone:909-395-9888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7325209800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes209800000XAllopathic & Osteopathic PhysiciansLegal MedicineGroup - Multi-Specialty