Basic Information
| Provider Information | |||||||||
| NPI: | 1245484005 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIFECARE FAMILY SERVICES | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 919 E COLLEGE ST | ||||||||
| Address2: | |||||||||
| City: | PULASKI | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384784432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157810013 | ||||||||
| FaxNumber: | 6156271441 | ||||||||
| Practice Location | |||||||||
| Address1: | 919 E COLLEGE ST | ||||||||
| Address2: | |||||||||
| City: | PULASKI | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384784432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157810013 | ||||||||
| FaxNumber: | 6156271441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2008 | ||||||||
| LastUpdateDate: | 11/06/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MAUCK | ||||||||
| AuthorizedOfficialFirstName: | LANDON | ||||||||
| AuthorizedOfficialMiddleName: | KENT | ||||||||
| AuthorizedOfficialTitleorPosition: | HR COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 6157810013 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LIFECARE FAMILY SERVICES | ||||||||
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| AuthorizedOfficialCredential: | BBA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | TN | N | Agencies | Case Management | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 3376955 | 01 | TN | GROUP MEDICARE | OTHER |