Provider Demographics
NPI:1871865394
Name:LIFESCAPE COMMUNITY SERVICES, INC.
Entity Type:Organization
Organization Name:LIFESCAPE COMMUNITY SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-963-1609
Mailing Address - Street 1:705 KILBURN AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61101-6550
Mailing Address - Country:US
Mailing Address - Phone:815-963-1609
Mailing Address - Fax:815-963-1627
Practice Address - Street 1:705 KILBURN AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61101-6550
Practice Address - Country:US
Practice Address - Phone:815-963-1609
Practice Address - Fax:815-963-1627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care