Provider Demographics
NPI:1609250976
Name:SPIRTILIFE
Entity Type:Organization
Organization Name:SPIRTILIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:E
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:724-465-2165
Mailing Address - Street 1:170 FR MARTIN TELENSON RD
Mailing Address - Street 2:
Mailing Address - City:PENN RUN
Mailing Address - State:PA
Mailing Address - Zip Code:15765-7336
Mailing Address - Country:US
Mailing Address - Phone:724-465-2165
Mailing Address - Fax:
Practice Address - Street 1:170 FR MARTIN TELENSON RD
Practice Address - Street 2:
Practice Address - City:PENN RUN
Practice Address - State:PA
Practice Address - Zip Code:15765-7336
Practice Address - Country:US
Practice Address - Phone:724-465-2165
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-16
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA327027324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility