Provider Demographics
NPI:1720458110
Name:LIFE SPAN INC
Entity Type:Organization
Organization Name:LIFE SPAN INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE
Authorized Official - Prefix:
Authorized Official - First Name:MERCEDES
Authorized Official - Middle Name:
Authorized Official - Last Name:BOATWRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:352-257-0575
Mailing Address - Street 1:265 SW LAKE FOREST WAY
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-1771
Mailing Address - Country:US
Mailing Address - Phone:813-477-0631
Mailing Address - Fax:
Practice Address - Street 1:265 SW LAKE FOREST WAY
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1771
Practice Address - Country:US
Practice Address - Phone:813-477-0631
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-29
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory