Provider Demographics
NPI:1083161202
Name:LIFEQUEST SUPPORT SERVICES LLC
Entity Type:Organization
Organization Name:LIFEQUEST SUPPORT SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-274-9471
Mailing Address - Street 1:99 ROYAL VISTA DR UNIT 408
Mailing Address - Street 2:
Mailing Address - City:BRANSON
Mailing Address - State:MO
Mailing Address - Zip Code:65616-6237
Mailing Address - Country:US
Mailing Address - Phone:417-274-9471
Mailing Address - Fax:
Practice Address - Street 1:99 ROYAL VISTA DR UNIT 408
Practice Address - Street 2:
Practice Address - City:BRANSON
Practice Address - State:MO
Practice Address - Zip Code:65616-6237
Practice Address - Country:US
Practice Address - Phone:417-274-9471
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities