Provider Demographics
NPI:1194336313
Name:LIFEPHYSICIAN, LLC
Entity type:Organization
Organization Name:LIFEPHYSICIAN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:V
Authorized Official - Last Name:CHANCE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:646-251-1992
Mailing Address - Street 1:5030 E LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94582-4822
Mailing Address - Country:US
Mailing Address - Phone:646-251-1992
Mailing Address - Fax:
Practice Address - Street 1:999 WATERSIDE DR STE 2525
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510-3316
Practice Address - Country:US
Practice Address - Phone:925-824-3198
Practice Address - Fax:949-655-8602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-11
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care