Healthcare Provider Details

I. General information

NPI: 1760210942
Provider Name (Legal Business Name): LIFECOURSE CARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 08/07/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 W MAIN ST
CARMEL IN
46032-1764
US

IV. Provider business mailing address

38 W MAIN ST
CARMEL IN
46032-1764
US

V. Phone/Fax

Practice location:
  • Phone: 225-241-2594
  • Fax:
Mailing address:
  • Phone: 225-241-2594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. TAMARA B SAMSON
Title or Position: VP REVENUE CYCLE
Credential:
Phone: 225-241-2594