Provider Demographics
NPI:1154918571
Name:FRIENDS FOR LIFE RESIDENTIAL CARE, LLC
Entity type:Organization
Organization Name:FRIENDS FOR LIFE RESIDENTIAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:STUART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-908-9440
Mailing Address - Street 1:1910 INDIAN WOOD CIR STE 100
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-4029
Mailing Address - Country:US
Mailing Address - Phone:419-279-8986
Mailing Address - Fax:419-573-1944
Practice Address - Street 1:1910 INDIAN WOOD CIR STE 100
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-4029
Practice Address - Country:US
Practice Address - Phone:419-908-9440
Practice Address - Fax:419-573-1944
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-31
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0198367Medicaid