Provider Demographics
NPI:1275251126
Name:LIFE CARE GROUP HOME
Entity Type:Organization
Organization Name:LIFE CARE GROUP HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE CEO
Authorized Official - Prefix:
Authorized Official - First Name:ABDUL
Authorized Official - Middle Name:K
Authorized Official - Last Name:MANSARAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:571-575-3555
Mailing Address - Street 1:6403 FRENCHMENS DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22312-1647
Mailing Address - Country:US
Mailing Address - Phone:571-575-3555
Mailing Address - Fax:
Practice Address - Street 1:14901 ROLLING MEADOWS RD
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-8338
Practice Address - Country:US
Practice Address - Phone:301-627-1675
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-17
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness