Provider Demographics
NPI:1407548266
Name:LIFESCORE FOUNDATION
Entity Type:Organization
Organization Name:LIFESCORE FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:BEYONCA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-251-1221
Mailing Address - Street 1:8244 S COTTAGE GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619-5302
Mailing Address - Country:US
Mailing Address - Phone:773-251-1221
Mailing Address - Fax:
Practice Address - Street 1:8244 S COTTAGE GROVE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60619-5302
Practice Address - Country:US
Practice Address - Phone:773-251-1221
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No251K00000XAgenciesPublic Health or Welfare
No251S00000XAgenciesCommunity/Behavioral Health
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM1000XAmbulatory Health Care FacilitiesClinic/CenterMigrant Health
No261QP2400XAmbulatory Health Care FacilitiesClinic/CenterPrison Health
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)