Provider Demographics
NPI:1083180095
Name:BARN LIFE LLC
Entity Type:Organization
Organization Name:BARN LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED REP
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:
Authorized Official - Last Name:PENROD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-289-9225
Mailing Address - Street 1:126 E 16TH ST
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-7704
Mailing Address - Country:US
Mailing Address - Phone:949-229-6853
Mailing Address - Fax:512-532-0923
Practice Address - Street 1:126 E 16TH ST
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-7704
Practice Address - Country:US
Practice Address - Phone:949-229-6853
Practice Address - Fax:512-532-0923
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-17
Last Update Date:2018-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA306005512OtherDEPARTMENT OF HEALTH CARE SERVICES