Provider Demographics
NPI:1376847251
Name:LIFE BRIDGES, INC.
Entity Type:Organization
Organization Name:LIFE BRIDGES, INC.
Other - Org Name:EDGEMON HOUSE
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LUCAS
Authorized Official - Middle Name:
Authorized Official - Last Name:QUEEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-472-5268
Mailing Address - Street 1:PO BOX 29
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37364-0029
Mailing Address - Country:US
Mailing Address - Phone:423-472-5268
Mailing Address - Fax:423-479-1492
Practice Address - Street 1:209 KILE LAKE ROAD
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37323
Practice Address - Country:US
Practice Address - Phone:423-472-5268
Practice Address - Fax:423-479-1492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-06
Last Update Date:2013-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3722363Medicaid