Provider Demographics
NPI:1780015412
Name:LIFEBACK LLC
Entity Type:Organization
Organization Name:LIFEBACK LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINSTRATOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARINETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:SEROTTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-872-8021
Mailing Address - Street 1:3366 DURHAM RD
Mailing Address - Street 2:
Mailing Address - City:DOYLESTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18902-1817
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4 PRINCESS RD
Practice Address - Street 2:BLDG 200 / SUITE 206
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648-2322
Practice Address - Country:US
Practice Address - Phone:609-482-3701
Practice Address - Fax:215-975-7300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-05
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children