1245489384 NPI number — LIFE CONNECT MEDICAL, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245489384 NPI number — LIFE CONNECT MEDICAL, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFE CONNECT MEDICAL, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245489384
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/03/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
36101 BOB HOPE DR
Provider Second Line Business Mailing Address:
STE. E-5 #117
Provider Business Mailing Address City Name:
RANCHO MIRAGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92270-2001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
760-217-0126
Provider Business Mailing Address Fax Number:
760-699-7750

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35900 BOB HOPE DR
Provider Second Line Business Practice Location Address:
SUITE # 100
Provider Business Practice Location Address City Name:
RANCHO MIRAGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92270-1766
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-699-7117
Provider Business Practice Location Address Fax Number:
760-699-7750
Provider Enumeration Date:
09/12/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KHANCHUSTAMBAHM
Authorized Official First Name:
PADMA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
760-464-2166

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  A86478 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: AV186 . This is a "MEDICARE PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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