Provider Demographics
NPI:1740500685
Name:LIFESPAN HEALTH SERVICE INC
Entity type:Organization
Organization Name:LIFESPAN HEALTH SERVICE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:REBEL
Authorized Official - Last Name:NOBLE
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN, DTS
Authorized Official - Phone:765-426-1425
Mailing Address - Street 1:2111 KLONDIKE RD
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-5124
Mailing Address - Country:US
Mailing Address - Phone:765-274-2168
Mailing Address - Fax:
Practice Address - Street 1:2111 KLONDIKE RD
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-5124
Practice Address - Country:US
Practice Address - Phone:765-274-2168
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-02
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28161533A251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health