Basic Information
| Provider Information | |||||||||
| NPI: | 1134699333 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | A LIVING CHANCE CLINICAL TRIALS, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 775 | ||||||||
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| City: | MURRIETA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925640775 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193081562 | ||||||||
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| Practice Location | |||||||||
| Address1: | 41593 WINCHESTER RD | ||||||||
| Address2: | |||||||||
| City: | TEMECULA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925904860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193081562 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2018 | ||||||||
| LastUpdateDate: | 12/06/2018 | ||||||||
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| AuthorizedOfficialLastName: | JACKSON | ||||||||
| AuthorizedOfficialFirstName: | WOODY | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9193081562 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.