Provider Demographics
NPI:1104905348
Name:LIFE DANCE INC
Entity type:Organization
Organization Name:LIFE DANCE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:MANUEL
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:352-335-1240
Mailing Address - Street 1:6417 NW 37TH DR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32653-0868
Mailing Address - Country:US
Mailing Address - Phone:352-335-1240
Mailing Address - Fax:
Practice Address - Street 1:6417 NW 37TH DR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32653-0868
Practice Address - Country:US
Practice Address - Phone:352-335-1240
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty