Provider Demographics
NPI:1760074991
Name:LIFEHOUSE BRIDGE GROUP, LLC
Entity Type:Organization
Organization Name:LIFEHOUSE BRIDGE GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-839-1525
Mailing Address - Street 1:412 LAUDER LN
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:IL
Mailing Address - Zip Code:60067-4562
Mailing Address - Country:US
Mailing Address - Phone:184-839-1525
Mailing Address - Fax:847-310-1239
Practice Address - Street 1:14127 LEAVITT AVE
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-3242
Practice Address - Country:US
Practice Address - Phone:847-839-1525
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-09
Last Update Date:2021-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health