Provider Demographics
NPI:1588862627
Name:L.I.F.E. INC.
Entity type:Organization
Organization Name:L.I.F.E. INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:FORREST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:410-735-5433
Mailing Address - Street 1:2822 HOLLINS FERRY ROAD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230
Mailing Address - Country:US
Mailing Address - Phone:410-735-5433
Mailing Address - Fax:410-735-5431
Practice Address - Street 1:4805 BENSON AVENUE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21227
Practice Address - Country:US
Practice Address - Phone:410-735-5433
Practice Address - Fax:410-735-5431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDDA-17237-05320600000X
MD702205100261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD7022055100Medicaid