Provider Demographics
NPI:1427723683
Name:LIFESTREAM TREATMENT CENTER LLC
Entity type:Organization
Organization Name:LIFESTREAM TREATMENT CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MISS
Authorized Official - First Name:YVETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:UMUGWANEZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-409-6515
Mailing Address - Street 1:2701 N 16TH ST STE 108
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-1264
Mailing Address - Country:US
Mailing Address - Phone:207-409-6515
Mailing Address - Fax:
Practice Address - Street 1:2701 N 16TH ST STE 108
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-1264
Practice Address - Country:US
Practice Address - Phone:207-409-6515
Practice Address - Fax:623-440-7746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)