Provider Demographics
NPI:1508103896
Name:LIFE CHRISTAIN OUTREACH
Entity Type:Organization
Organization Name:LIFE CHRISTAIN OUTREACH
Other - Org Name:LIFE ENTERPRISES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:
Authorized Official - Last Name:ORDWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-256-6155
Mailing Address - Street 1:1250 N DOZIER STATION RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65202-7798
Mailing Address - Country:US
Mailing Address - Phone:573-256-6155
Mailing Address - Fax:
Practice Address - Street 1:3251 PINETREE DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-1706
Practice Address - Country:US
Practice Address - Phone:573-875-1141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-07
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO856254206Medicaid