Provider Demographics
NPI:1194940395
Name:LIFE CARE HOSPICE CORP.
Entity type:Organization
Organization Name:LIFE CARE HOSPICE CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DPCS/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DIVINA
Authorized Official - Middle Name:D
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:323-807-5196
Mailing Address - Street 1:5539 E SPRING ST.
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808
Mailing Address - Country:US
Mailing Address - Phone:714-222-7665
Mailing Address - Fax:
Practice Address - Street 1:5539 E SPRING ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90808-3736
Practice Address - Country:US
Practice Address - Phone:714-222-7665
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-15
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25G00000X251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based