Provider Demographics
NPI:1760522569
Name:LIFESTREAM,INC
Entity Type:Organization
Organization Name:LIFESTREAM,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:LATAWIEC
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-993-1991
Mailing Address - Street 1:PO BOX 50487
Mailing Address - Street 2:
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02745-0017
Mailing Address - Country:US
Mailing Address - Phone:508-993-1991
Mailing Address - Fax:508-991-5228
Practice Address - Street 1:70 MILL RD
Practice Address - Street 2:
Practice Address - City:ACUSHNET
Practice Address - State:MA
Practice Address - Zip Code:02743-2658
Practice Address - Country:US
Practice Address - Phone:508-998-2162
Practice Address - Fax:508-998-8626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1305182Medicaid