Healthcare Provider Details

I. General information

NPI: 1508456302
Provider Name (Legal Business Name): KKC LIFE MANAGEMENT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2021
Last Update Date: 01/25/2021
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 S MARKET ST
LISBON OH
44432-1232
US

IV. Provider business mailing address

136 S MARKET ST
LISBON OH
44432-1232
US

V. Phone/Fax

Practice location:
  • Phone: 234-736-8425
  • Fax: 330-954-0880
Mailing address:
  • Phone: 234-736-8425
  • Fax: 330-954-0880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: ERICA ATKINS HOLSHUE
Title or Position: QMHS
Credential: QMHS
Phone: 234-736-8425