=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699968677
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRATIVE LIFE SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2007
-----------------------------------------------------
Last Update Date | 08/22/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2010 W CHESTER PIKE SUITE 314
-----------------------------------------------------
City | HAVERTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19083-2700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-789-6005
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2010 W CHESTER PIKE SUITE 314
-----------------------------------------------------
City | HAVERTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19083-2700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-789-6005
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MARK D BESDEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 610-789-6005
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------