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NPI Code Detail

MEDICARE: LIFE-LINE, INC.

MEDICARE: LIFE-LINE, INC.
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
1261QM0855XAdolescent and Children Mental Health Clinic/Center11832UT
2261QR0405XSubstance Use Disorder Rehabilitation Clinic/Center11832UT

General Provider Information

NPI Number : 1174711873
Entity Type Code : Organization
Provider Name (Legal Business Name) : LIFE-LINE, INC.
Provider Business Mailing Address
First Line : 1130 W CENTER ST
Second Line :
City : NORTH SALT LAKE
State : UT
Zip : 84054-2917
Country : US
Telephone Number : 801-936-4000
Fax Number :
Provider Business Practice Location Address
First Line : 1130 W CENTER ST
Second Line :
City : NORTH SALT LAKE
State : UT
Zip : 84054-2917
Country : US
Telephone Number : 801-936-4000
Fax Number :
Authorized Official
Title or Position : CHIEF EXECUTIVE OFFICER
Name : MR. SHANE R PETERSEN
Credential : MBA
Telephone Number : 801-936-4000
Provider Enumeration Date : 10/09/2007
Last Update Date : 10/21/2011

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Directions to “LIFE-LINE, INC. ” Practice Location

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