Provider Demographics
NPI:1043332430
Name:LIFE SKILLS REHABILITATION CENTER, L.L.C.
Entity Type:Organization
Organization Name:LIFE SKILLS REHABILITATION CENTER, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:MAX
Authorized Official - Last Name:MICKELSON
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:307-389-9169
Mailing Address - Street 1:3405 WHITE MOUNTAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-4729
Mailing Address - Country:US
Mailing Address - Phone:307-362-6029
Mailing Address - Fax:
Practice Address - Street 1:3405 WHITE MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-4729
Practice Address - Country:US
Practice Address - Phone:307-362-6029
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services