Provider Demographics
NPI:1043917560
Name:FAMILY LIFE FOUNDATION INCORPORATION
Entity Type:Organization
Organization Name:FAMILY LIFE FOUNDATION INCORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:ADEBODUN
Authorized Official - Last Name:OWOLABI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-985-7590
Mailing Address - Street 1:11721 REISTERSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:REISTERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21136-3320
Mailing Address - Country:US
Mailing Address - Phone:443-405-3744
Mailing Address - Fax:443-405-3778
Practice Address - Street 1:11721 REISTERSTOWN RD
Practice Address - Street 2:
Practice Address - City:REISTERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21136-3320
Practice Address - Country:US
Practice Address - Phone:443-405-3744
Practice Address - Fax:443-405-3778
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-15
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD5766138000OtherNPI
MD5766138000Medicaid
MD766138000Medicaid