Provider Demographics
NPI:1912896572
Name:LIFEBRIDGE SUPPORTED LIVING LLC
Entity type:Organization
Organization Name:LIFEBRIDGE SUPPORTED LIVING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXCUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RAPHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ONYEKACHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:147-046-1714
Mailing Address - Street 1:4113 EUBANK BLVD NE STE 200D
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-3482
Mailing Address - Country:US
Mailing Address - Phone:470-461-7149
Mailing Address - Fax:
Practice Address - Street 1:4113 EUBANK BLVD NE STE 200D
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-3482
Practice Address - Country:US
Practice Address - Phone:470-461-7149
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-30
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility