Provider Demographics
NPI:1942698790
Name:LIFE SPAN HOME, INC
Entity Type:Organization
Organization Name:LIFE SPAN HOME, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUTHORN
Authorized Official - Suffix:
Authorized Official - Credentials:MACP
Authorized Official - Phone:916-965-0110
Mailing Address - Street 1:4041 BRIDGE STREET
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628
Mailing Address - Country:US
Mailing Address - Phone:916-965-0110
Mailing Address - Fax:916-965-0102
Practice Address - Street 1:4041 BRIDGE STREET
Practice Address - Street 2:
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628
Practice Address - Country:US
Practice Address - Phone:916-965-0110
Practice Address - Fax:916-965-0102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-02
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health