Provider Demographics
NPI:1699968677
Name:INTEGRATIVE LIFE SERVICES
Entity type:Organization
Organization Name:INTEGRATIVE LIFE SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:BESDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-789-6005
Mailing Address - Street 1:2010 W CHESTER PIKE
Mailing Address - Street 2:SUITE 314
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-2700
Mailing Address - Country:US
Mailing Address - Phone:610-789-6005
Mailing Address - Fax:
Practice Address - Street 1:2010 W CHESTER PIKE
Practice Address - Street 2:SUITE 314
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-2700
Practice Address - Country:US
Practice Address - Phone:610-789-6005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101269497-0001Medicaid