Provider Demographics
NPI:1265891543
Name:LIFE SOLUTIONS OUTPATIENT CORP
Entity type:Organization
Organization Name:LIFE SOLUTIONS OUTPATIENT CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:STAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KOTEI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-583-5388
Mailing Address - Street 1:1341 EAST TENNESSEE STREET
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308
Mailing Address - Country:US
Mailing Address - Phone:850-583-5388
Mailing Address - Fax:
Practice Address - Street 1:3111 MAHAN DR
Practice Address - Street 2:SUITE 20 #113
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5548
Practice Address - Country:US
Practice Address - Phone:850-583-5388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-16
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty