MEDICARE: LIFE MENTORING 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	261QM0855X	Adolescent and Children Mental Health Clinic/Center

General Provider Information

NPI Number	:	1235773664
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE MENTORING INC.

Provider Business Mailing Address
First Line	:	123 HARRINGTON AVE APT 2B
Second Line	:
City	:	CROWN POINT
State	:	IN
Zip	:	46307-3843
Country	:	US
Telephone Number	:	219-730-2909
Fax Number	:

Provider Business Practice Location Address
First Line	:	123 HARRINGTON AVE APT 2B
Second Line	:
City	:	CROWN POINT
State	:	IN
Zip	:	46307-3843
Country	:	US
Telephone Number	:	219-730-2909
Fax Number	:

Authorized Official
Title or Position	:	CO-PARTNER
Name	:	MR. ROBERT JAMES DUTKO
Credential	:
Telephone Number	:	219-730-2909

Provider Enumeration Date	:	10/29/2019
Last Update Date	:	10/29/2019

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