Provider Demographics
NPI:1831313436
Name:LIFE INCLUDED
Entity Type:Organization
Organization Name:LIFE INCLUDED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMARA
Authorized Official - Middle Name:J
Authorized Official - Last Name:LOFTHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:435-201-2074
Mailing Address - Street 1:178 SOUTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84701
Mailing Address - Country:US
Mailing Address - Phone:435-896-8997
Mailing Address - Fax:
Practice Address - Street 1:160 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:UT
Practice Address - Zip Code:84701-2557
Practice Address - Country:US
Practice Address - Phone:435-201-2074
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT0998251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========002Medicaid