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General NPI Number Information
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NPI Number | 1497388458
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Entity Type | Organization
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Legal Business Name | LIFE PUSH, LLC
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Dates
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Enumeration Date | 02/19/2020
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Last Update Date | 02/19/2020
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Provider Practice Location Address
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Address Line | 308 CRAGHEAD ST
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City | DANVILLE
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State | VA
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Zip | 24541-1470
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Country | US
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Telephone | 434-774-8539
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Fax | 434-857-4220
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Provider Business Mailing Address
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Address Line | PO BOX 193
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City | WHITSETT
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State | NC
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Zip | 27377-0193
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Country | US
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Telephone | 919-891-0205
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Fax | 434-857-4220
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. NICHOLAS CORY STURDIFEN SR.
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Credential | MBA, MA
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Telephone | 919-891-0205
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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