=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124729314
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE'S INTENTION LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2023
-----------------------------------------------------
Last Update Date | 03/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 920 SW FRAZER AVE STE 212
-----------------------------------------------------
City | PENDLETON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97801-2802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-969-1941
-----------------------------------------------------
Fax | 541-429-4941
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 920 SW FRAZER AVE STE 212
-----------------------------------------------------
City | PENDLETON
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97801-2802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-969-1941
-----------------------------------------------------
Fax | 541-429-4941
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | AMY MADRIGAL-BATES
-----------------------------------------------------
Credential | LPCA, CADC II, QMHP
-----------------------------------------------------
Telephone | 541-969-1941
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 261QR0800X
-----------------------------------------------------
Taxonomy Name | Recovery Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------