Healthcare Provider Details

I. General information

NPI: 1083180095
Provider Name (Legal Business Name): BARN LIFE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2018
Last Update Date: 10/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 E 16TH ST
COSTA MESA CA
92627-7704
US

IV. Provider business mailing address

126 E 16TH ST
COSTA MESA CA
92627-7704
US

V. Phone/Fax

Practice location:
  • Phone: 949-229-6853
  • Fax: 512-532-0923
Mailing address:
  • Phone: 949-229-6853
  • Fax: 512-532-0923

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: TYLER PENROD
Title or Position: AUTHORIZED REP
Credential:
Phone: 832-289-9225