| The Life Center Complex, Inc | |
|
1624 Jessup St Wilmington DE 19802-4210 | |
| (302) 552-3574 | |
| (302) 552-3561 |
| Full Name | The Life Center Complex, Inc |
|---|---|
| Speciality | Clinic/Center |
| Location | 1624 Jessup St, Wilmington, Delaware |
| Authorized Official Name and Position | Forrest Watson (PRESIDENT) |
| Authorized Official Contact | 3025523574 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| The Life Center Complex, Inc 812 Philadelphia Pike Ste F Wilmington DE 19809-2371 Ph: (302) 407-5316 | The Life Center Complex, Inc 1624 Jessup St Wilmington DE 19802-4210 Ph: (302) 552-3574 |
| NPI Number | 1770808578 |
|---|---|
| Provider Enumeration Date | 04/05/2010 |
| Last Update Date | 03/28/2024 |
| Certification Date | 03/28/2024 |
| Medicare PECOS PAC ID | 6800038076 |
|---|---|
| Medicare Enrollment ID | O20130819000252 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1770808578 | NPI | - | NPPES |
| 1770808578 | Medicaid | DE |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 103TP2701X | Psychologist - Group Psychotherapy | 71788 (Delaware) | Secondary |
| 261QC1500X | Clinic/center - Community Health | (Delaware) | Primary |
| Provider Name | Herman M Ellis |
|---|---|
| Provider Type | Practitioner - Preventive Medicine |
| Provider Identifiers | NPI Number: 1386768612 PECOS PAC ID: 5698727782 Enrollment ID: I20050217000107 |
| Provider Name | Mwazhuwa L Kuretu |
|---|---|
| Provider Type | Practitioner - Thoracic Surgery |
| Provider Identifiers | NPI Number: 1881633220 PECOS PAC ID: 8921137738 Enrollment ID: I20100603000265 |
| Provider Name | Shariyfa Fields |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1205144060 PECOS PAC ID: 7517270622 Enrollment ID: I20150720000350 |
| Provider Name | Norwood J Coleman |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1861721987 PECOS PAC ID: 7911212444 Enrollment ID: I20150813009449 |
| Provider Name | Ngozi T Chiekwu |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1427396373 PECOS PAC ID: 1355574468 Enrollment ID: I20180504000030 |
| Provider Name | Santa Murtano |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1104403377 PECOS PAC ID: 8729469713 Enrollment ID: I20220722000037 |
| Provider Name | Danielle M Lopez |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1659907830 PECOS PAC ID: 3274914262 Enrollment ID: I20220722000054 |
| Provider Name | Sharon Farrell |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1124343124 PECOS PAC ID: 4183090269 Enrollment ID: I20221013003023 |
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