Provider Demographics
NPI:1508456302
Name:KKC LIFE MANAGEMENT SERVICES
Entity Type:Organization
Organization Name:KKC LIFE MANAGEMENT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:QMHS
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:ATKINS HOLSHUE
Authorized Official - Suffix:
Authorized Official - Credentials:QMHS
Authorized Official - Phone:234-736-8425
Mailing Address - Street 1:136 S MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LISBON
Mailing Address - State:OH
Mailing Address - Zip Code:44432-1232
Mailing Address - Country:US
Mailing Address - Phone:234-736-8425
Mailing Address - Fax:330-954-0880
Practice Address - Street 1:136 S MARKET ST
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:OH
Practice Address - Zip Code:44432-1232
Practice Address - Country:US
Practice Address - Phone:234-736-8425
Practice Address - Fax:330-954-0880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty
No251B00000XAgenciesCase ManagementGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0381705Medicaid