Provider Demographics
NPI:1942086442
Name:LIFELINE ADULT DAY CARE CENTER LLC
Entity Type:Organization
Organization Name:LIFELINE ADULT DAY CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KHADRA
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-541-4647
Mailing Address - Street 1:2512 7TH AVE S STE F1
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-8747
Mailing Address - Country:US
Mailing Address - Phone:701-541-4647
Mailing Address - Fax:
Practice Address - Street 1:2512 7TH AVE S STE F1
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-8747
Practice Address - Country:US
Practice Address - Phone:701-541-4647
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-31
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services