MEDICARE: LIFE TREATMENT CENTERS

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	806-0-ASR	IN

General Provider Information

NPI Number	:	1437444692
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE TREATMENT CENTERS

Provider Business Mailing Address
First Line	:	1402 S MICHIGAN ST
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46613-2214
Country	:	US
Telephone Number	:	574-233-5433
Fax Number	:	574-239-6407

Provider Business Practice Location Address
First Line	:	1402 S MICHIGAN ST
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46613-2214
Country	:	US
Telephone Number	:	574-233-5433
Fax Number	:	574-239-6407

Authorized Official
Title or Position	:	CEO
Name	:	MR. DAVID NOWAK
Credential	:	MSBA,MBA,PHR
Telephone Number	:	574-233-5433

Provider Enumeration Date	:	06/16/2011
Last Update Date	:	06/16/2011

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Directions to “LIFE TREATMENT CENTERS ” Practice Location

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