Provider Demographics
NPI:1689719650
Name:FOR LIFE SERVICES-COMMUNITY CARE, LLC
Entity Type:Organization
Organization Name:FOR LIFE SERVICES-COMMUNITY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TRA
Authorized Official - Middle Name:
Authorized Official - Last Name:AHIA
Authorized Official - Suffix:
Authorized Official - Credentials:PH D
Authorized Official - Phone:602-405-4962
Mailing Address - Street 1:PO BOX 8222
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-0120
Mailing Address - Country:US
Mailing Address - Phone:602-405-4962
Mailing Address - Fax:702-973-6392
Practice Address - Street 1:16671 N LITCHFIELD RD APT 223
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-7080
Practice Address - Country:US
Practice Address - Phone:602-405-4962
Practice Address - Fax:702-973-6392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZBH 2690251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ107384Medicare ID - Type UnspecifiedAHCCCS