Provider Demographics
NPI:1467113084
Name:MAINSTAY LIFE SERVICES
Entity Type:Organization
Organization Name:MAINSTAY LIFE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF PROGRAM OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:
Authorized Official - Last Name:DOUGLASS
Authorized Official - Suffix:
Authorized Official - Credentials:MPM
Authorized Official - Phone:412-344-3640
Mailing Address - Street 1:200 ROESSLER RD
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15220-1037
Mailing Address - Country:US
Mailing Address - Phone:412-344-3640
Mailing Address - Fax:412-344-5486
Practice Address - Street 1:200 ROESSLER RD
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15220-1037
Practice Address - Country:US
Practice Address - Phone:412-344-3640
Practice Address - Fax:412-344-5486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-05
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA100000916Medicaid