Provider Demographics
NPI:1376982132
Name:LIFESTREAM HOPE & WELLNESS CENTER, INC.
Entity Type:Organization
Organization Name:LIFESTREAM HOPE & WELLNESS CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:W
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:BSN, RN, PHN
Authorized Official - Phone:714-555-1212
Mailing Address - Street 1:2030 EAST 4TH STREET
Mailing Address - Street 2:SUITE 115D
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705
Mailing Address - Country:US
Mailing Address - Phone:714-541-1100
Mailing Address - Fax:
Practice Address - Street 1:2030 EAST 4TH STREET
Practice Address - Street 2:SUITE 115D
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705
Practice Address - Country:US
Practice Address - Phone:714-541-1100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GS HEALTHCARE MANAGEMENT, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-06-14
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health