Provider Demographics
NPI:1073664694
Name:LIFELINE RESOURCES, LLC
Entity Type:Organization
Organization Name:LIFELINE RESOURCES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/VICE-PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:A
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:515-256-8001
Mailing Address - Street 1:3125 DOUGLAS AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50310-5310
Mailing Address - Country:US
Mailing Address - Phone:515-256-8001
Mailing Address - Fax:515-256-8082
Practice Address - Street 1:3125 DOUGLAS AVE STE 100
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50310-5310
Practice Address - Country:US
Practice Address - Phone:515-256-8001
Practice Address - Fax:515-256-8082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02581101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0401894Medicaid
IA0401892Medicaid
IA600013244OtherMAGELLAN
IA0015180Medicaid