Provider Demographics
NPI:1497388458
Name:LIFE PUSH, LLC
Entity Type:Organization
Organization Name:LIFE PUSH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:CORY
Authorized Official - Last Name:STURDIFEN
Authorized Official - Suffix:SR
Authorized Official - Credentials:MBA, MA
Authorized Official - Phone:919-891-0205
Mailing Address - Street 1:PO BOX 193
Mailing Address - Street 2:
Mailing Address - City:WHITSETT
Mailing Address - State:NC
Mailing Address - Zip Code:27377-0193
Mailing Address - Country:US
Mailing Address - Phone:919-891-0205
Mailing Address - Fax:434-857-4220
Practice Address - Street 1:308 CRAGHEAD ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-1470
Practice Address - Country:US
Practice Address - Phone:434-774-8539
Practice Address - Fax:434-857-4220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-19
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health