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General NPI Number Information
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NPI Number | 1912335217
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Entity Type | Organization
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Legal Business Name | LIFESTYLE CHANGES COUNSELING
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Dates
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Enumeration Date | 10/23/2013
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Last Update Date | 10/23/2013
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Provider Practice Location Address
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Address Line | 371 LOCUST ST S
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City | TWIN FALLS
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State | ID
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Zip | 83301-7837
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Country | US
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Telephone | 208-734-5230
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Fax |
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Provider Business Mailing Address
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Address Line | 371 LOCUST ST S
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City | TWIN FALLS
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State | ID
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Zip | 83301-7837
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Country | US
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Telephone | 208-734-5230
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. WILLIAM L VIRTUE SR.
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Credential |
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Telephone | 12087345230
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR0405X
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Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
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License Number |
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License Number State | ID
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