Provider Demographics
NPI:1457879520
Name:LIFEBACK OF PENNSYLVANIA LLC
Entity type:Organization
Organization Name:LIFEBACK OF PENNSYLVANIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARINETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:SEROTTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:609-482-3701
Mailing Address - Street 1:10 S CLINTON ST STE 100
Mailing Address - Street 2:
Mailing Address - City:DOYLESTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18901-4220
Mailing Address - Country:US
Mailing Address - Phone:609-482-3701
Mailing Address - Fax:215-975-7300
Practice Address - Street 1:10 S CLINTON ST STE 100
Practice Address - Street 2:
Practice Address - City:DOYLESTOWN
Practice Address - State:PA
Practice Address - Zip Code:18901-4220
Practice Address - Country:US
Practice Address - Phone:609-482-3701
Practice Address - Fax:215-975-7300
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-08
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health