Provider Demographics
NPI:1285356360
Name:FOUNDATIONS FOR LIFE CLINIC LLC
Entity type:Organization
Organization Name:FOUNDATIONS FOR LIFE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:T
Authorized Official - Last Name:MANZANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:737-787-7367
Mailing Address - Street 1:PO BOX 242
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:OR
Mailing Address - Zip Code:97449-0242
Mailing Address - Country:US
Mailing Address - Phone:737-787-7367
Mailing Address - Fax:
Practice Address - Street 1:70909 DEVORE ARM RD
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:OR
Practice Address - Zip Code:97449-8502
Practice Address - Country:US
Practice Address - Phone:737-787-7367
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-14
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty