1679877518 NPI number — LIFE BRIDGES, INC.

Table of content: (NPI 1679877518)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679877518 NPI number — LIFE BRIDGES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFE BRIDGES, 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:
MCINTIRE HOUSE
Provider Other Organization Name Type Code:
5
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:
1679877518
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 29
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37364-0029
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-472-5268
Provider Business Mailing Address Fax Number:
423-479-1492

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
207 KILE LAKE ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37323
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-478-7700
Provider Business Practice Location Address Fax Number:
423-478-7772
Provider Enumeration Date:
01/07/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
QUEEN
Authorized Official First Name:
LUCAS
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
423-472-5268

Provider Taxonomy Codes

  • Taxonomy code: 315P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3722363 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".