Provider Demographics
NPI:1619403219
Name:MISTER LIFE COACH
Entity Type:Organization
Organization Name:MISTER LIFE COACH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LIFE COACH
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:631-553-7131
Mailing Address - Street 1:PO BOX 283
Mailing Address - Street 2:
Mailing Address - City:REX
Mailing Address - State:GA
Mailing Address - Zip Code:30273-0283
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3681 N DECATUR RD APT R11
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-1062
Practice Address - Country:US
Practice Address - Phone:631-553-7131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-03
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children