Basic Information
| Provider Information | |||||||||
| NPI: | 1326237785 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIFESKILLS, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | LIFESKILLS ADULT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 380 SUWANNEE TRAIL ST. | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421037956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2709015000 | ||||||||
| FaxNumber: | 2708425268 | ||||||||
| Practice Location | |||||||||
| Address1: | 380 SUWANNEE TRAIL ST. | ||||||||
| Address2: | |||||||||
| City: | BOWLING GREEN | ||||||||
| State: | KY | ||||||||
| PostalCode: | 421037956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2709015000 | ||||||||
| FaxNumber: | 2708425268 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2007 | ||||||||
| LastUpdateDate: | 12/12/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BEAVERS | ||||||||
| AuthorizedOfficialFirstName: | JOE DAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2709015000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/12/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 800004 | KY | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 27004019 | 05 | KY | MEDICAID |