Provider Demographics
NPI:1588296461
Name:FULL LIFE LLP
Entity type:Organization
Organization Name:FULL LIFE LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-539-5108
Mailing Address - Street 1:12309 GARA DR
Mailing Address - Street 2:
Mailing Address - City:KODIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99615-9317
Mailing Address - Country:US
Mailing Address - Phone:907-539-5108
Mailing Address - Fax:
Practice Address - Street 1:12309 GARA DR
Practice Address - Street 2:
Practice Address - City:KODIAK
Practice Address - State:AK
Practice Address - Zip Code:99615-9317
Practice Address - Country:US
Practice Address - Phone:907-487-2181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-07
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation SpecialistGroup - Multi-Specialty