Basic Information
| Provider Information | |||||||||
| NPI: | 1205882677 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIFESTAGES - SAMARITAN CENTERS FOR WOMEN LTD | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 9000 N MAIN ST | ||||||||
| Address2: | SUITE 232 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454151180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372778988 | ||||||||
| FaxNumber: | 9378322421 | ||||||||
| Practice Location | |||||||||
| Address1: | 9000 N MAIN ST | ||||||||
| Address2: | SUITE 232 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454151180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372778988 | ||||||||
| FaxNumber: | 9378322421 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2006 | ||||||||
| LastUpdateDate: | 06/12/2013 | ||||||||
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| AuthorizedOfficialLastName: | GUERRANT | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE ASSISTANCE | ||||||||
| AuthorizedOfficialTelephone: | 9372778988 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 2077523 | 05 | OH | MEDICAID |