Provider Demographics
NPI:1508078973
Name:LIFEGUIDE, INC
Entity Type:Organization
Organization Name:LIFEGUIDE, INC
Other - Org Name:LIFEGUIDE HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LATESHA
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-820-7582
Mailing Address - Street 1:519 FOREST PKWY
Mailing Address - Street 2:SUITE 270
Mailing Address - City:FOREST PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30297-6142
Mailing Address - Country:US
Mailing Address - Phone:404-363-6922
Mailing Address - Fax:404-363-6925
Practice Address - Street 1:656 INDIAN TRAIL LILBURN RD NW STE 208
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-6872
Practice Address - Country:US
Practice Address - Phone:770-557-1079
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-05
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA031-R-0050251E00000X
261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA276046116AMedicaid
GA838117320AMedicaid