Provider Demographics
NPI:1003537390
Name:LIFESAVER INTERVENTION CENTER INC
Entity Type:Organization
Organization Name:LIFESAVER INTERVENTION CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSON
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, APRN, FNP-BC
Authorized Official - Phone:877-989-9198
Mailing Address - Street 1:7933 S YATES BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-1102
Mailing Address - Country:US
Mailing Address - Phone:877-989-9198
Mailing Address - Fax:
Practice Address - Street 1:7933 S YATES BLVD STE 205
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-1102
Practice Address - Country:US
Practice Address - Phone:877-989-9198
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-06
Last Update Date:2022-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2800XAmbulatory Health Care FacilitiesClinic/CenterMethadoneGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty