Provider Demographics
NPI:1003568817
Name:LIFEWAY TRAINING INSTITUTE CO
Entity type:Organization
Organization Name:LIFEWAY TRAINING INSTITUTE CO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JULENE
Authorized Official - Middle Name:DOROTHY
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:229-403-9964
Mailing Address - Street 1:410 4TH ST SE
Mailing Address - Street 2:
Mailing Address - City:CAIRO
Mailing Address - State:GA
Mailing Address - Zip Code:39828-2775
Mailing Address - Country:US
Mailing Address - Phone:229-403-9964
Mailing Address - Fax:
Practice Address - Street 1:410 4TH ST SE
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:GA
Practice Address - Zip Code:39828-2775
Practice Address - Country:US
Practice Address - Phone:229-403-9964
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-23
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1083071898Medicaid
GA1083071898OtherBLUE CROSS BLUE SHIELD/ANTHEM