MEDICARE: SPRING OF LIFE FAMILY SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	4942	OK

General Provider Information

NPI Number	:	1003234907
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPRING OF LIFE FAMILY SERVICES LLC

Provider Business Mailing Address
First Line	:	7814 NORTHWEST 94TH, SUITE B
Second Line	:
City	:	OKC
State	:	OK
Zip	:	73162-6201
Country	:	US
Telephone Number	:	405-414-0043
Fax Number	:

Provider Business Practice Location Address
First Line	:	7814 NW 94TH ST STE B
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73162-6203
Country	:	US
Telephone Number	:	405-414-0043
Fax Number	:

Authorized Official
Title or Position	:	OWNER/EXECUTIVE DIRECTOR
Name	:	RUTH KINYUY LANGE
Credential	:	LPC
Telephone Number	:	405-414-0043

Provider Enumeration Date	:	03/29/2014
Last Update Date	:	03/29/2014

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