Healthcare Provider Details

I. General information

NPI: 1164791778
Provider Name (Legal Business Name): LYFE INTERVENTION SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2011
Last Update Date: 12/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 PUTMAN STREET
FOUNTAIN INN SC
29644
US

IV. Provider business mailing address

401 PUTMAN STREET
FOUNTAIN INN SC
29644
US

V. Phone/Fax

Practice location:
  • Phone: 864-862-6912
  • Fax:
Mailing address:
  • Phone: 864-862-6912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number251S00000X
License Number StateSC

VIII. Authorized Official

Name: MR. DARIUS DURAND LAGROON
Title or Position: CEO
Credential: BS
Phone: 864-862-6912