Provider Demographics
NPI:1902359417
Name:LIFE INTERRUPTED TREATMENT, LLC
Entity Type:Organization
Organization Name:LIFE INTERRUPTED TREATMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:CAIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-857-6879
Mailing Address - Street 1:1910 FERRELL ST APT 10
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-1254
Mailing Address - Country:US
Mailing Address - Phone:678-857-6879
Mailing Address - Fax:
Practice Address - Street 1:1910 FERRELL ST APT 10
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-1254
Practice Address - Country:US
Practice Address - Phone:678-857-6879
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-01
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
NVNV20161278438252Y00000X
NV2003291-048-122343900000X
NV2105351319347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No251S00000XAgenciesCommunity/Behavioral Health
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No347C00000XTransportation ServicesPrivate Vehicle