Provider Demographics
NPI:1902204050
Name:LIFE LIFE
Entity Type:Organization
Organization Name:LIFE LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:E
Authorized Official - Last Name:DELFOSSE
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:401-932-9342
Mailing Address - Street 1:30 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02852-5112
Mailing Address - Country:US
Mailing Address - Phone:401-295-5269
Mailing Address - Fax:
Practice Address - Street 1:30 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NORTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02852-5112
Practice Address - Country:US
Practice Address - Phone:401-295-5269
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-05
Last Update Date:2014-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRN48162251K00000X
RIRN32761251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251K00000XAgenciesPublic Health or Welfare