Provider Demographics
NPI:1740417542
Name:LIFETIES,INC./RAINBOW HOUSE
Entity Type:Organization
Organization Name:LIFETIES,INC./RAINBOW HOUSE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O./FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:INZANA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-771-1600
Mailing Address - Street 1:2205 PENNINGTON RD
Mailing Address - Street 2:
Mailing Address - City:EWING
Mailing Address - State:NJ
Mailing Address - Zip Code:08638-1212
Mailing Address - Country:US
Mailing Address - Phone:609-771-1600
Mailing Address - Fax:
Practice Address - Street 1:1301 W STATE ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08618-5227
Practice Address - Country:US
Practice Address - Phone:609-394-6747
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFETIES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-06-18
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0184691Medicaid