Healthcare Provider Details

I. General information

NPI: 1811145030
Provider Name (Legal Business Name): QUALITY LIFESTYLE SERVICE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2008
Last Update Date: 02/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5102 HWY 58 SUITE 4
CHATTANOOGA TN
37416-1646
US

IV. Provider business mailing address

5102 HWY 58 STE 4
CHATTANOOGA TN
37416-1646
US

V. Phone/Fax

Practice location:
  • Phone: 423-386-5714
  • Fax: 423-386-5716
Mailing address:
  • Phone: 423-386-5714
  • Fax: 423-386-5716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License NumberC-27A
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number21T
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberC219-058-9914
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberC219-058-9913
License Number StateTN
# 5
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License NumberC-27A
License Number StateTN

VIII. Authorized Official

Name: MRS. URSULA DESHAWN DIAL
Title or Position: DIRECTOR/ADMINISTRATOR
Credential:
Phone: 423-386-5714