Provider Demographics
NPI:1528240785
Name:LIFEHOUSE INE
Entity type:Organization
Organization Name:LIFEHOUSE INE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE/ADMINISTRATION
Authorized Official - Prefix:MS
Authorized Official - First Name:MERLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:TEAGUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:415-472-2373
Mailing Address - Street 1:100 SMITH RANCH RD
Mailing Address - Street 2:SUITE 309
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-1900
Mailing Address - Country:US
Mailing Address - Phone:415-472-2373
Mailing Address - Fax:415-472-5739
Practice Address - Street 1:100 SMITH RANCH RD
Practice Address - Street 2:SUITE 309
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-1900
Practice Address - Country:US
Practice Address - Phone:415-472-2373
Practice Address - Fax:415-472-5739
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACMCSUBJ49Medicaid