MEDICARE: LIFEWORKS SUBSTANCE ABUSE SERVICES 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	101YM0800X	Mental Health Counselor	MH8565	FL
2	324500000X	Substance Abuse Rehabilitation Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MH8565	OTHER	FL	STATE OF FLORIDA

General Provider Information

NPI Number	:	1487055919
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFEWORKS SUBSTANCE ABUSE SERVICES LLC

Provider Business Mailing Address
First Line	:	4678 TAMIAMI TRL
Second Line	:	#105
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33980-2900
Country	:	US
Telephone Number	:	941-979-5023
Fax Number	:	941-979-5064

Provider Business Practice Location Address
First Line	:	4678 TAMIAMI TRL
Second Line	:	#105
City	:	PORT CHARLOTTE
State	:	FL
Zip	:	33980-2900
Country	:	US
Telephone Number	:	941-979-5023
Fax Number	:	941-979-5064

Authorized Official
Title or Position	:	CEO
Name	:	DR. RHOADIE LADD
Credential	:
Telephone Number	:	941-979-5023

Provider Enumeration Date	:	09/16/2014
Last Update Date	:	06/29/2016

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