Healthcare Provider Details

I. General information

NPI: 1235497710
Provider Name (Legal Business Name): LIFESTYLE HOSPICE FOUNDATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2012
Last Update Date: 08/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2390 SW 4TH AVE
ONTARIO OR
97914-1852
US

IV. Provider business mailing address

2390 SW 4TH AVE
ONTARIO OR
97914-1852
US

V. Phone/Fax

Practice location:
  • Phone: 541-216-6468
  • Fax: 541-216-6469
Mailing address:
  • Phone: 541-216-6468
  • Fax: 541-216-6469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberNPC-0003805
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License NumberNPC-0003805
License Number StateOR

VIII. Authorized Official

Name: MR. LELAND KENT FIFE
Title or Position: EXECUTIVE DIRECTOR
Credential: M.S.
Phone: 541-216-6468