Provider Demographics
NPI:1760101794
Name:LIFETORCH RECOVERY CENTER & WELLNESS LLC
Entity Type:Organization
Organization Name:LIFETORCH RECOVERY CENTER & WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:
Authorized Official - Last Name:LAGAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-564-1263
Mailing Address - Street 1:423 N CRESTON APT 260
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-7085
Mailing Address - Country:US
Mailing Address - Phone:952-564-1263
Mailing Address - Fax:
Practice Address - Street 1:1041 W SOLANA AVE
Practice Address - Street 2:
Practice Address - City:AJO
Practice Address - State:AZ
Practice Address - Zip Code:85321-2337
Practice Address - Country:US
Practice Address - Phone:952-564-1263
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-23
Last Update Date:2022-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use DisorderGroup - Single Specialty
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness