Provider Demographics
NPI:1124542360
Name:LIFE ALLIANCE, LLC
Entity type:Organization
Organization Name:LIFE ALLIANCE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ABDISALLAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:ABDULLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:952-777-4625
Mailing Address - Street 1:8609 LYNDALE AVE S STE 213C
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55420-2769
Mailing Address - Country:US
Mailing Address - Phone:612-200-9466
Mailing Address - Fax:952-777-4627
Practice Address - Street 1:8609 LYNDALE AVE S, SUITE 213C
Practice Address - Street 2:
Practice Address - City:BLOOMIGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-5542
Practice Address - Country:US
Practice Address - Phone:952-777-4625
Practice Address - Fax:952-777-4627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-31
Last Update Date:2017-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 251C00000X, 252Y00000X
MN1087364-1-HCBS252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes252Y00000XAgenciesEarly Intervention Provider Agency
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251C00000XAgenciesDay Training, Developmentally Disabled Services