=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487375465
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LYFE ENRICHING PROFESSIONAL SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2022
-----------------------------------------------------
Last Update Date | 09/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 32 GORSUCH RD
-----------------------------------------------------
City | LUTHERVILLE TIMONIUM
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21093-4215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-500-1954
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 32 GORSUCH RD
-----------------------------------------------------
City | LUTHERVILLE TIMONIUM
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21093-4215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-500-1954
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CHRISTINA L BEADENKOPF
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 443-500-1954
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------