Provider Demographics
NPI:1982248704
Name:LIFE WAY SERVICES
Entity Type:Organization
Organization Name:LIFE WAY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:IVANA
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-296-7875
Mailing Address - Street 1:7228 STATESMAN BLVD
Mailing Address - Street 2:
Mailing Address - City:RUTHER GLEN
Mailing Address - State:VA
Mailing Address - Zip Code:22546-5246
Mailing Address - Country:US
Mailing Address - Phone:804-296-7875
Mailing Address - Fax:
Practice Address - Street 1:7228 STATESMAN BLVD
Practice Address - Street 2:
Practice Address - City:RUTHER GLEN
Practice Address - State:VA
Practice Address - Zip Code:22546-5246
Practice Address - Country:US
Practice Address - Phone:804-296-7875
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8042967875Medicaid