MEDICARE: LIFEBRIDGE SUPPORT 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	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

General Provider Information

NPI Number	:	1326908765
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFEBRIDGE SUPPORT LLC

Provider Business Mailing Address
First Line	:	802 N ST SW
Second Line	:
City	:	CEDAR RAPIDS
State	:	IA
Zip	:	52404-2708
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	802 N ST SW
Second Line	:
City	:	CEDAR RAPIDS
State	:	IA
Zip	:	52404-2708
Country	:	US
Telephone Number	:	208-801-1123
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	CLAIRE KIOTA
Credential	:
Telephone Number	:	208-801-1123

Provider Enumeration Date	:	11/17/2025
Last Update Date	:	11/17/2025

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Directions to “LIFEBRIDGE SUPPORT LLC ” Practice Location

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