Provider Demographics
NPI:1437539749
Name:RUTHERFORD LIFE SERVICES, INC.
Entity Type:Organization
Organization Name:RUTHERFORD LIFE SERVICES, INC.
Other - Org Name:RUTHERFORD LIFE CARE (PROGRAM)
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:P
Authorized Official - Last Name:FREEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:QP
Authorized Official - Phone:828-286-4352
Mailing Address - Street 1:230 FAIRGROUND RD
Mailing Address - Street 2:
Mailing Address - City:SPINDALE
Mailing Address - State:NC
Mailing Address - Zip Code:28160-2203
Mailing Address - Country:US
Mailing Address - Phone:828-286-4352
Mailing Address - Fax:828-287-3295
Practice Address - Street 1:859 THUNDER RD
Practice Address - Street 2:
Practice Address - City:SPINDALE
Practice Address - State:NC
Practice Address - Zip Code:28160-1152
Practice Address - Country:US
Practice Address - Phone:828-288-1697
Practice Address - Fax:828-288-9910
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RUTHERFORD LIFE SERVICES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-02
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-081-065251C00000X
251C00000X, 251S00000X, 261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408856Medicaid