Healthcare Provider Details

I. General information

NPI: 1568864734
Provider Name (Legal Business Name): LIFE & HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2014
Last Update Date: 08/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1814 CUMBERLAND AVENUE
MIDDLESBORO KY
40965
US

IV. Provider business mailing address

1814 CUMBERLAND AVENUE
MIDDLESBORO KY
40965
US

V. Phone/Fax

Practice location:
  • Phone: 606-242-2519
  • Fax: 606-242-2520
Mailing address:
  • Phone: 606-242-2519
  • Fax: 606-242-2520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number800179
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number40049
License Number StateKY

VIII. Authorized Official

Name: TINA T POORE
Title or Position: SECRETARY
Credential: OM
Phone: 606-242-2519