Provider Demographics
NPI:1982318192
Name:LIFE SOURCE TRAINING INSTITUTE INC
Entity Type:Organization
Organization Name:LIFE SOURCE TRAINING INSTITUTE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AVIS
Authorized Official - Middle Name:
Authorized Official - Last Name:ATTAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-682-7143
Mailing Address - Street 1:3036 REDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92501-2008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3036 REDWOOD DR
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-2008
Practice Address - Country:US
Practice Address - Phone:951-682-7143
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-11
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)