MEDICARE: LIFE IN RECOVERY, LLC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	302F00000X	Exclusive Provider Organization	9021	MN

General Provider Information

NPI Number	:	1023293503
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE IN RECOVERY, LLC.

Provider Business Mailing Address
First Line	:	304 8TH ST SE
Second Line	:
City	:	LITTLE FALLS
State	:	MN
Zip	:	56345-3241
Country	:	US
Telephone Number	:	320-360-4755
Fax Number	:	320-632-2781

Provider Business Practice Location Address
First Line	:	304 8TH ST SE
Second Line	:
City	:	LITTLE FALLS
State	:	MN
Zip	:	56345-3241
Country	:	US
Telephone Number	:	320-360-4755
Fax Number	:	320-632-2781

Authorized Official
Title or Position	:	OWNER
Name	:	DOREEN MARIE LOOMIS
Credential	:
Telephone Number	:	320-632-2598

Provider Enumeration Date	:	01/03/2008
Last Update Date	:	01/03/2008

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