Provider Demographics
NPI:1629519715
Name:LIFE RECOVERY CENTER
Entity Type:Organization
Organization Name:LIFE RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTRO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-525-4179
Mailing Address - Street 1:9028 GALE BLVD UNIT 1
Mailing Address - Street 2:
Mailing Address - City:THORNTON
Mailing Address - State:CO
Mailing Address - Zip Code:80260-4939
Mailing Address - Country:US
Mailing Address - Phone:720-044-0426
Mailing Address - Fax:
Practice Address - Street 1:11658 HURON ST
Practice Address - Street 2:SUITE 400
Practice Address - City:NORTHGLENN
Practice Address - State:CO
Practice Address - Zip Code:80234-2919
Practice Address - Country:US
Practice Address - Phone:303-252-4179
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1740608959Medicaid