Provider Demographics
NPI:1699031500
Name:T.A.C.K. FOR LIFE
Entity Type:Organization
Organization Name:T.A.C.K. FOR LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:WEBB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-205-2013
Mailing Address - Street 1:PO BOX 183
Mailing Address - Street 2:3041 KY RT 7
Mailing Address - City:WAYLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41666
Mailing Address - Country:US
Mailing Address - Phone:606-447-2493
Mailing Address - Fax:
Practice Address - Street 1:3041 KY RTE 7
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:KY
Practice Address - Zip Code:41666
Practice Address - Country:US
Practice Address - Phone:606-447-2493
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-04
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 251B00000X, 251C00000X, 251S00000X
KY252Y00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No252Y00000XAgenciesEarly Intervention Provider AgencyGroup - Multi-Specialty
No253Z00000XAgenciesIn Home Supportive Care