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General NPI Number Information
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NPI Number | 1760813653
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Entity Type | Organization
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Legal Business Name | LIFE, A CENTER FOR INDEPENDENT LIVING
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Dates
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Enumeration Date | 12/03/2013
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Last Update Date | 05/21/2025
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Provider Practice Location Address
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Address Line | 640 PERSHING AVE 1
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City | POCATELLO
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State | ID
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Zip | 83201-3702
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Country | US
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Telephone | 208-232-2747
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Fax | 208-232-2753
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Provider Business Mailing Address
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Address Line | 640 PERSHING AVE 1
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City | POCATELLO
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State | ID
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Zip | 83201-3702
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Country | US
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Telephone | 208-232-2747
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Fax | 208-232-2753
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MICHAEL LEFEVOR
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Credential |
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Telephone | 208-232-2747
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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Taxonomy #2
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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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Taxonomy #3
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number | M8054374
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License Number State | ID
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