Provider Demographics
NPI:1962797738
Name:LIFE CARE MEDICAL CLINIC A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:LIFE CARE MEDICAL CLINIC A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:LEONARD
Authorized Official - Last Name:GOFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-664-4044
Mailing Address - Street 1:1211 N VERMONT AVE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90029-1748
Mailing Address - Country:US
Mailing Address - Phone:323-664-4044
Mailing Address - Fax:
Practice Address - Street 1:1211 N VERMONT AVE
Practice Address - Street 2:SUITE 207
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-1748
Practice Address - Country:US
Practice Address - Phone:323-664-4044
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFE CARE MEDICAL CLINIC A PROFESSIONAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-06-09
Last Update Date:2011-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC30424207P00000X, 208D00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No251E00000XAgenciesHome HealthGroup - Multi-Specialty