Healthcare Provider Details

I. General information

NPI: 1588862627
Provider Name (Legal Business Name): L.I.F.E. INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 03/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4805 BENSON AVENUE
BALTIMORE MD
21227
US

IV. Provider business mailing address

2822 HOLLINS FERRY ROAD
BALTIMORE MD
21230
US

V. Phone/Fax

Practice location:
  • Phone: 410-735-5433
  • Fax: 410-735-5431
Mailing address:
  • Phone: 410-735-5433
  • Fax: 410-735-5431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number702205100
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberDDA-17237-05
License Number StateMD

VIII. Authorized Official

Name: THERESA MARIE FORREST
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 410-735-5433