Basic Information
Provider Information | |||||||||
NPI: | 1669401816 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LIFESKILLS, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 07/01/2006 | ||||||||
LastUpdateDate: | 12/11/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BEAVERS | ||||||||
AuthorizedOfficialFirstName: | JOE DAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 2709015000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/11/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X |   |   | N |   | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |   | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 30604011 | 05 | KY |   | MEDICAID |