Healthcare Provider Details

I. General information

NPI: 1689892473
Provider Name (Legal Business Name): LIFELINE CONNECTIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 03/01/2023
Certification Date: 03/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 E FOURTH PLAIN BLVD BUILDING 17
VANCOUVER WA
98661-3753
US

IV. Provider business mailing address

PO BOX 1678
VANCOUVER WA
98668-1678
US

V. Phone/Fax

Practice location:
  • Phone: 360-397-8246
  • Fax:
Mailing address:
  • Phone: 360-397-8246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
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
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License NumberRTF - 1075
License Number StateWA

VIII. Authorized Official

Name: KINH REYNOLDS
Title or Position: CFO
Credential:
Phone: 360-397-8246