Provider Demographics
NPI:1720751688
Name:LIFE360 COMMUNITY SERVICES
Entity type:Organization
Organization Name:LIFE360 COMMUNITY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COUNSELING SERVICES DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GENE
Authorized Official - Middle Name:ESTRADA
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:I
Authorized Official - Credentials:MS
Authorized Official - Phone:417-658-5409
Mailing Address - Street 1:2220 W CHESTERFIELD BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-8683
Mailing Address - Country:US
Mailing Address - Phone:417-447-9000
Mailing Address - Fax:
Practice Address - Street 1:836 S SUBURBAN AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-6774
Practice Address - Country:US
Practice Address - Phone:417-658-5409
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-27
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1578916946Medicaid