Provider Demographics
NPI:1174140438
Name:LIFE EQUITY HEALTHCARE LLC
Entity type:Organization
Organization Name:LIFE EQUITY HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:KORITA
Authorized Official - Middle Name:SHERELLE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:305-492-5175
Mailing Address - Street 1:710 SW 64TH WAY
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33023-1540
Mailing Address - Country:US
Mailing Address - Phone:305-492-5175
Mailing Address - Fax:
Practice Address - Street 1:1931 NW 150TH AVE STE 269
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-2884
Practice Address - Country:US
Practice Address - Phone:786-372-0053
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-02
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service