Provider Demographics
NPI:1750649521
Name:LIFESPAN, INC
Entity Type:Organization
Organization Name:LIFESPAN, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:STALER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-868-3210
Mailing Address - Street 1:1900 FAIRGROVE AVE
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:OH
Mailing Address - Zip Code:45011-1966
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1900 FAIRGROVE AVE
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:OH
Practice Address - Zip Code:45011-1966
Practice Address - Country:US
Practice Address - Phone:513-868-3210
Practice Address - Fax:513-868-3249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-30
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1000444251S00000X
OHI.0003470-SUPV251S00000X
OHE.0004344-SUPV251S00000X
OHS.1000832251S00000X
OH35-029775251S00000X
OHI.1000343251S00000X
OHE.0601020251S00000X
OHE.0600276-SUPV251S00000X
OHI.0008038SUPV251S00000X
OHI.0010181-SUPV251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2864431Medicaid