Provider Demographics
NPI:1376701730
Name:LIFE RENEWAL RESROUCES
Entity Type:Organization
Organization Name:LIFE RENEWAL RESROUCES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANN
Authorized Official - Middle Name:M
Authorized Official - Last Name:THARP
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:970-402-4579
Mailing Address - Street 1:6814 ANTIGUA DR UNIT 18
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-6936
Mailing Address - Country:US
Mailing Address - Phone:970-223-2506
Mailing Address - Fax:
Practice Address - Street 1:2114 N LINCOLN AVE STE 106
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-3858
Practice Address - Country:US
Practice Address - Phone:970-402-4579
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-01
Last Update Date:2008-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20051340355251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health