Provider Demographics
NPI:1245489384
Name:LIFE CONNECT MEDICAL, INC
Entity type:Organization
Organization Name:LIFE CONNECT MEDICAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PADMA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHANCHUSTAMBAHM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-464-2166
Mailing Address - Street 1:36101 BOB HOPE DR
Mailing Address - Street 2:STE. E-5 #117
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-2001
Mailing Address - Country:US
Mailing Address - Phone:760-217-0126
Mailing Address - Fax:760-699-7750
Practice Address - Street 1:35900 BOB HOPE DR
Practice Address - Street 2:SUITE # 100
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-1766
Practice Address - Country:US
Practice Address - Phone:760-699-7117
Practice Address - Fax:760-699-7750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-12
Last Update Date:2016-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86478261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAV186OtherMEDICARE PTAN
CAAV186OtherMEDICARE PTAN