MEDICARE: LIFECHOICES TREATMENT SERVICES, INC

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	324500000X	Substance Abuse Rehabilitation Facility	430049AN	CA

General Provider Information

NPI Number	:	1215178199
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFECHOICES TREATMENT SERVICES, INC

Provider Business Mailing Address
First Line	:	1157 E TAYLOR ST
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95112-1658
Country	:	US
Telephone Number	:	408-971-7811
Fax Number	:	408-998-4337

Provider Business Practice Location Address
First Line	:	1157 E TAYLOR ST
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95112-1658
Country	:	US
Telephone Number	:	408-971-7811
Fax Number	:	408-998-4337

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. BETTY LICKING
Credential	:
Telephone Number	:	408-799-7372

Provider Enumeration Date	:	03/23/2009
Last Update Date	:	03/23/2009

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