Provider Demographics
NPI:1376230896
Name:ARCHAIC LIFESTYLE, INC.
Entity Type:Organization
Organization Name:ARCHAIC LIFESTYLE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED AGENT
Authorized Official - Prefix:
Authorized Official - First Name:LATRIECE
Authorized Official - Middle Name:
Authorized Official - Last Name:SESSION
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-506-3974
Mailing Address - Street 1:41768 W BARCELONA DR
Mailing Address - Street 2:
Mailing Address - City:MARICOPA
Mailing Address - State:AZ
Mailing Address - Zip Code:85138-4445
Mailing Address - Country:US
Mailing Address - Phone:562-506-3974
Mailing Address - Fax:
Practice Address - Street 1:41768 W BARCELONA DR
Practice Address - Street 2:
Practice Address - City:MARICOPA
Practice Address - State:AZ
Practice Address - Zip Code:85138-4445
Practice Address - Country:US
Practice Address - Phone:562-506-3974
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-24
Last Update Date:2023-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness