Provider Demographics
NPI:1679863344
Name:NATIVE AMERICAN LIFELINES, INC.
Entity Type:Organization
Organization Name:NATIVE AMERICAN LIFELINES, INC.
Other - Org Name:LIFELINES FOUNDATION, INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-837-2258
Mailing Address - Street 1:106 CLAY ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-3501
Mailing Address - Country:US
Mailing Address - Phone:410-837-2258
Mailing Address - Fax:410-837-2692
Practice Address - Street 1:106 CLAY ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-3501
Practice Address - Country:US
Practice Address - Phone:410-837-2258
Practice Address - Fax:410-837-2692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-14
Last Update Date:2011-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD9848261QD0000X
MD904244261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder