Provider Demographics
NPI:1922492057
Name:LIVE FOR LIFE CYPRESS
Entity Type:Organization
Organization Name:LIVE FOR LIFE CYPRESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TROY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-577-4142
Mailing Address - Street 1:3023 N BRONZEWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:ERDA
Mailing Address - State:UT
Mailing Address - Zip Code:84074-3302
Mailing Address - Country:US
Mailing Address - Phone:801-577-4142
Mailing Address - Fax:
Practice Address - Street 1:3023 N BRONZEWOOD CIR
Practice Address - Street 2:
Practice Address - City:ERDA
Practice Address - State:UT
Practice Address - Zip Code:84074-3302
Practice Address - Country:US
Practice Address - Phone:801-577-4142
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-26
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9716253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency