Basic Information
| Provider Information | |||||||||
| NPI: | 1952474017 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIFENET SERVICES INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LIFENET COMMUNITY BEHAVIORAL HEALTHCARE | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 9708 SKILLMAN STREET | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752435150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142215433 | ||||||||
| FaxNumber: | 2149321977 | ||||||||
| Practice Location | |||||||||
| Address1: | 9708 SKILLMAN STREET | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752435150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142215433 | ||||||||
| FaxNumber: | 2149321977 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 11/20/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROBERTSON | ||||||||
| AuthorizedOfficialFirstName: | BOB | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2142215433 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 251S00000X | 1887-A | TX | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | A099677 | 01 | TX | NORTHSTAR VENDOR NUMBER | OTHER | 284464901 | 05 | TX | MEDICAID |