MEDICARE: LIFE SKILLS REHABILITATION CENTER, L.L.C.

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	251C00000X	Developmentally Disabled Services Day Training Agency

General Provider Information

NPI Number	:	1043332430
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE SKILLS REHABILITATION CENTER, L.L.C.

Provider Business Mailing Address
First Line	:	3405 WHITE MOUNTAIN BLVD
Second Line	:
City	:	ROCK SPRINGS
State	:	WY
Zip	:	82901-4729
Country	:	US
Telephone Number	:	307-362-6029
Fax Number	:

Provider Business Practice Location Address
First Line	:	3405 WHITE MOUNTAIN BLVD
Second Line	:
City	:	ROCK SPRINGS
State	:	WY
Zip	:	82901-4729
Country	:	US
Telephone Number	:	307-362-6029
Fax Number	:

Authorized Official
Title or Position	:	PARTNER
Name	:	MR. GORDON MAX MICKELSON III
Credential	:
Telephone Number	:	307-389-9169

Provider Enumeration Date	:	04/04/2007
Last Update Date	:	08/22/2020

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