Provider Demographics
NPI:1023543162
Name:LIFE HEALTH
Entity Type:Organization
Organization Name:LIFE HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RECRUITER
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-730-1902
Mailing Address - Street 1:3382 KNIGHTON RDG
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-2160
Mailing Address - Country:US
Mailing Address - Phone:770-780-7825
Mailing Address - Fax:
Practice Address - Street 1:3382 KNIGHTON RDG
Practice Address - Street 2:
Practice Address - City:POWDER SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30127-2160
Practice Address - Country:US
Practice Address - Phone:770-780-7825
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-26
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN167846261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA208D00000XMedicaid
GA208D00000XMedicaid