Provider Demographics
NPI:1114450707
Name:ADVANCED LIFE PROVIDERS
Entity Type:Organization
Organization Name:ADVANCED LIFE PROVIDERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:LA TONYA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:RAFE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:847-830-7385
Mailing Address - Street 1:239 WILLOW RD
Mailing Address - Street 2:
Mailing Address - City:MATTESON
Mailing Address - State:IL
Mailing Address - Zip Code:60443-1068
Mailing Address - Country:US
Mailing Address - Phone:847-830-7385
Mailing Address - Fax:
Practice Address - Street 1:239 WILLOW RD
Practice Address - Street 2:
Practice Address - City:MATTESON
Practice Address - State:IL
Practice Address - Zip Code:60443-1068
Practice Address - Country:US
Practice Address - Phone:847-830-7385
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-10
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041348482174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174H00000XOther Service ProvidersHealth EducatorGroup - Multi-Specialty