Provider Demographics
NPI:1679816045
Name:LIFESHARE MIDWEST, LLC
Entity Type:Organization
Organization Name:LIFESHARE MIDWEST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:P
Authorized Official - Last Name:BOYNTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-491-1762
Mailing Address - Street 1:155 DOW ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03101-1299
Mailing Address - Country:US
Mailing Address - Phone:603-625-8825
Mailing Address - Fax:603-625-8875
Practice Address - Street 1:155 DOW ST
Practice Address - Street 2:SUITE 300
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03101-1299
Practice Address - Country:US
Practice Address - Phone:603-625-8825
Practice Address - Fax:603-625-8875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-03
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL201000005C251C00000X
253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No253J00000XAgenciesFoster Care Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========-100Medicaid