Provider Demographics
NPI:1710012000
Name:LIFETIME POTENTIALS, INC.
Entity Type:Organization
Organization Name:LIFETIME POTENTIALS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KAY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:VANOVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-693-0994
Mailing Address - Street 1:PO BOX 798
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:KY
Mailing Address - Zip Code:41339
Mailing Address - Country:US
Mailing Address - Phone:606-693-0994
Mailing Address - Fax:606-693-0959
Practice Address - Street 1:43 LJ LANE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:KY
Practice Address - Zip Code:41339
Practice Address - Country:US
Practice Address - Phone:606-693-0994
Practice Address - Fax:606-693-0959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY007700784251C00000X
KY251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY33001256Medicaid
KY7100179820Medicaid
KY3300125600Medicaid