MEDICARE: LIFT FOR LIFE ACADEMY

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	251300000X	Local Education Agency (LEA)

General Provider Information

NPI Number	:	1649477241
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFT FOR LIFE ACADEMY

Provider Business Mailing Address
First Line	:	1731 S BROADWAY
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63104-4050
Country	:	US
Telephone Number	:	314-436-2337
Fax Number	:	314-231-1299

Provider Business Practice Location Address
First Line	:	1731 S BROADWAY
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63104-4050
Country	:	US
Telephone Number	:	314-436-2337
Fax Number	:	314-231-1299

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. MARSHALL COHEN
Credential	:
Telephone Number	:	314-436-2337

Provider Enumeration Date	:	06/28/2007
Last Update Date	:	10/01/2007

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Directions to “LIFT FOR LIFE ACADEMY ” Practice Location

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