Basic Information
| Provider Information | |||||||||
| NPI: | 1487121687 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIFESPRING, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 480 EVERSMAN DR | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475463548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124823020 | ||||||||
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| Practice Location | |||||||||
| Address1: | 480 EVERSMAN DR | ||||||||
| Address2: | |||||||||
| City: | JASPER | ||||||||
| State: | IN | ||||||||
| PostalCode: | 475463548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124823020 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2018 | ||||||||
| LastUpdateDate: | 05/01/2020 | ||||||||
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| AuthorizedOfficialLastName: | STAWAR | ||||||||
| AuthorizedOfficialFirstName: | TERRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8122061234 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LIFESPRING, INC | ||||||||
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| NPICertificationDate: | 05/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 261QM1300X | N | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 300018353 | 05 | IN | MEDICAID |