Provider Demographics
NPI:1184005803
Name:LIFE SOLUTIONS OUTPATIENT CORP
Entity Type:Organization
Organization Name:LIFE SOLUTIONS OUTPATIENT CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:TAYLOR
Authorized Official - Middle Name:E
Authorized Official - Last Name:GAINES
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD,CAP
Authorized Official - Phone:855-454-3376
Mailing Address - Street 1:1347 E TENNESSEE ST
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-5107
Mailing Address - Country:US
Mailing Address - Phone:850-583-5388
Mailing Address - Fax:850-583-5388
Practice Address - Street 1:1347 E TENNESSEE ST
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5107
Practice Address - Country:US
Practice Address - Phone:850-583-5388
Practice Address - Fax:850-583-5388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0237AD383201261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder