Provider Demographics
NPI:1740651579
Name:NEW LIFE OUTPATIENT CENTER
Entity type:Organization
Organization Name:NEW LIFE OUTPATIENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSS
Authorized Official - Suffix:
Authorized Official - Credentials:IADC
Authorized Official - Phone:563-355-0055
Mailing Address - Street 1:2322 E KIMBERLY RD
Mailing Address - Street 2:STE. 200 NORTH
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-7205
Mailing Address - Country:US
Mailing Address - Phone:563-355-0055
Mailing Address - Fax:563-355-0101
Practice Address - Street 1:2322 E KIMBERLY RD
Practice Address - Street 2:STE. 200 NORTH
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-7205
Practice Address - Country:US
Practice Address - Phone:563-355-0055
Practice Address - Fax:563-355-0101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-20
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA101YA0400X251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health