Provider Demographics
NPI:1427018639
Name:LIFESPAN, INC.
Entity Type:Organization
Organization Name:LIFESPAN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:G
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:812-332-2265
Mailing Address - Street 1:3749 E. COVENANTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-5454
Mailing Address - Country:US
Mailing Address - Phone:812-332-2265
Mailing Address - Fax:812-334-0853
Practice Address - Street 1:800 BELL TRACE CIR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-4405
Practice Address - Country:US
Practice Address - Phone:812-335-2445
Practice Address - Fax:812-353-7576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN001614-1251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN157524Medicare ID - Type UnspecifiedMEDICAID CERTIFICATION