Healthcare Provider Details

I. General information

NPI: 1811512239
Provider Name (Legal Business Name): LIFESPRING, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2020
Last Update Date: 07/20/2020
Certification Date: 07/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2277 W FRONTAGE RD
AUSTIN IN
47102-8820
US

IV. Provider business mailing address

460 SPRING ST
JEFFERSONVILLE IN
47130-3452
US

V. Phone/Fax

Practice location:
  • Phone: 812-413-3117
  • Fax:
Mailing address:
  • Phone: 812-206-1362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TERRY STAWAR
Title or Position: CEO
Credential:
Phone: 812-206-1234