Provider Demographics
NPI:1386897650
Name:FRIENDS FOR LIFE, LLC
Entity type:Organization
Organization Name:FRIENDS FOR LIFE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:SHUPE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-710-0210
Mailing Address - Street 1:2228 S 2325 W
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:UT
Mailing Address - Zip Code:84075-9282
Mailing Address - Country:US
Mailing Address - Phone:801-710-0210
Mailing Address - Fax:
Practice Address - Street 1:2228 S 2325 W
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:UT
Practice Address - Zip Code:84075-9282
Practice Address - Country:US
Practice Address - Phone:801-710-0210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-29
Last Update Date:2008-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities