Healthcare Provider Details

I. General information

NPI: 1467295782
Provider Name (Legal Business Name): LIFEKEEPERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2024
Last Update Date: 06/14/2024
Certification Date: 06/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

N6706 OLD RIVER RD
PORTAGE WI
53901-9522
US

IV. Provider business mailing address

515 WASHINGTON ST STE A
PORTAGE WI
53901-2442
US

V. Phone/Fax

Practice location:
  • Phone: 608-742-2788
  • Fax:
Mailing address:
  • Phone: 608-745-9004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: THOMAS AUGUSTINE
Title or Position: PRESIDENT AND CEO
Credential:
Phone: 608-697-5987