Healthcare Provider Details

I. General information

NPI: 1871865394
Provider Name (Legal Business Name): LIFESCAPE COMMUNITY SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2012
Last Update Date: 01/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 KILBURN AVE
ROCKFORD IL
61101-6550
US

IV. Provider business mailing address

705 KILBURN AVE
ROCKFORD IL
61101-6550
US

V. Phone/Fax

Practice location:
  • Phone: 815-963-1609
  • Fax: 815-963-1627
Mailing address:
  • Phone: 815-963-1609
  • Fax: 815-963-1627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. CAROL GREEN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 815-963-1609