Healthcare Provider Details

I. General information

NPI: 1427018639
Provider Name (Legal Business Name): LIFESPAN, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 BELL TRACE CIR
BLOOMINGTON IN
47408-4405
US

IV. Provider business mailing address

3749 E. COVENANTER DRIVE
BLOOMINGTON IN
47401-5454
US

V. Phone/Fax

Practice location:
  • Phone: 812-335-2445
  • Fax: 812-353-7576
Mailing address:
  • Phone: 812-332-2265
  • Fax: 812-334-0853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number001614-1
License Number StateIN

VIII. Authorized Official

Name: DR. STEPHEN G. MOORE
Title or Position: PRESIDENT/CEO
Credential: MD
Phone: 812-332-2265