MEDICARE: INTEGRATED LIFESTYLES 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		MO

General Provider Information

NPI Number	:	1801121397
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATED LIFESTYLES LLC

Provider Business Mailing Address
First Line	:	820 BOURN AVE
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65203-1459
Country	:	US
Telephone Number	:	573-445-4409
Fax Number	:	573-445-4409

Provider Business Practice Location Address
First Line	:	820 BOURN AVE
Second Line	:
City	:	COLUMBIA
State	:	MO
Zip	:	65203-1459
Country	:	US
Telephone Number	:	573-445-4409
Fax Number	:	573-445-4409

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MR. JON GILLIOM
Credential	:
Telephone Number	:	573-445-4409

Provider Enumeration Date	:	10/16/2009
Last Update Date	:	10/16/2009

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Directions to “INTEGRATED LIFESTYLES LLC ” Practice Location

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