Provider Demographics
NPI:1447602552
Name:LIFE OF PURPOSE - PENNSYLVANIA
Entity Type:Organization
Organization Name:LIFE OF PURPOSE - PENNSYLVANIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:BRANDEN
Authorized Official - Middle Name:
Authorized Official - Last Name:COLUCCIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-636-9322
Mailing Address - Street 1:PO BOX 826742
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-6742
Mailing Address - Country:US
Mailing Address - Phone:877-636-9322
Mailing Address - Fax:866-417-4309
Practice Address - Street 1:225 E CITY AVE STE 15
Practice Address - Street 2:
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-1724
Practice Address - Country:US
Practice Address - Phone:877-636-9322
Practice Address - Fax:866-417-4309
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFE OF PURPOSE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-07-13
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA467132261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder