Provider Demographics
NPI:1205016490
Name:LIFE INDIVIDUAL FAMILY ENRICHMENT SERVICES
Entity Type:Organization
Organization Name:LIFE INDIVIDUAL FAMILY ENRICHMENT SERVICES
Other - Org Name:LIFE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:LEWIS
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-523-8287
Mailing Address - Street 1:153 WHITE FAWN DR
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-1464
Mailing Address - Country:US
Mailing Address - Phone:386-523-8287
Mailing Address - Fax:386-523-8287
Practice Address - Street 1:153 WHITE FAWN DR
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-1464
Practice Address - Country:US
Practice Address - Phone:386-523-8287
Practice Address - Fax:386-523-8287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-06
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management