MEDICARE: LIFELINE BEHAVIORAL HEALTH, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	323P00000X	Psychiatric Residential Treatment Facility
2	261QM0855X	Adolescent and Children Mental Health Clinic/Center
3	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center
4	3245S0500X	Children's Substance Abuse Rehabilitation Facility

General Provider Information

NPI Number	:	1780884742
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFELINE BEHAVIORAL HEALTH, LLC

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	:	07/18/2007
Last Update Date	:	04/10/2015

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