MEDICARE: LIFE OF PURPOSE - PENNSYLVANIA

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	261QR0405X	Substance Use Disorder Rehabilitation Clinic/Center	467132	PA

General Provider Information

NPI Number	:	1992251326
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE OF PURPOSE - PENNSYLVANIA

Provider Business Mailing Address
First Line	:	PO BOX 826742
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19182-6742
Country	:	US
Telephone Number	:	877-636-9322
Fax Number	:	866-417-4309

Provider Business Practice Location Address
First Line	:	1035 VIRGINIA DR STE 120
Second Line	:
City	:	FORT WASHINGTON
State	:	PA
Zip	:	19034-3103
Country	:	US
Telephone Number	:	877-636-9322
Fax Number	:	866-417-4309

Authorized Official
Title or Position	:	CFO
Name	:	BRANDEN COLUCCIO
Credential	:
Telephone Number	:	267-907-8000

Provider Enumeration Date	:	08/26/2016
Last Update Date	:	01/25/2019

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