Healthcare Provider Details

I. General information

NPI: 1962103176
Provider Name (Legal Business Name): LIFE'S INTENTION BACK TO BASICS INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2023
Last Update Date: 03/14/2023
Certification Date: 03/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 SW FRAZER AVE STE 212
PENDLETON OR
97801-2802
US

IV. Provider business mailing address

920 SW FRAZER AVE STE 212
PENDLETON OR
97801-2802
US

V. Phone/Fax

Practice location:
  • Phone: 541-969-1941
  • Fax:
Mailing address:
  • Phone: 541-969-1941
  • Fax: 541-429-4941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: AMY MADRIGAL-BATES
Title or Position: OWNER
Credential: LPCA, CADC II, QMHP
Phone: 541-969-1941