Provider Demographics
NPI:1245607589
Name:LIFE MD
Entity type:Organization
Organization Name:LIFE MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:L
Authorized Official - Last Name:VOLLARO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-954-8281
Mailing Address - Street 1:12718 OAK RUN CT
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33436-6134
Mailing Address - Country:US
Mailing Address - Phone:866-954-8281
Mailing Address - Fax:
Practice Address - Street 1:1901 S CONGRESS AVE
Practice Address - Street 2:SUITE 150
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-6556
Practice Address - Country:US
Practice Address - Phone:866-954-8281
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-21
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty