Provider Demographics
NPI:1588087050
Name:LIFE UNIVERSITY HEALTH CENTER
Entity type:Organization
Organization Name:LIFE UNIVERSITY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DEAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DONG
Authorized Official - Middle Name:WOO
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-323-9001
Mailing Address - Street 1:555 W REDONDO BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-1612
Mailing Address - Country:US
Mailing Address - Phone:310-323-9001
Mailing Address - Fax:310-756-0004
Practice Address - Street 1:555 W REDONDO BEACH BLVD
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-1612
Practice Address - Country:US
Practice Address - Phone:310-323-9001
Practice Address - Fax:310-756-0004
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-02-03
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC8057320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities