Provider Demographics
NPI:1053691063
Name:LIFECARE FAMILY SERVICES
Entity type:Organization
Organization Name:LIFECARE FAMILY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HR COORDINATER
Authorized Official - Prefix:
Authorized Official - First Name:LANDON
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:MAUCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-781-0013
Mailing Address - Street 1:103 JV MANGUBAT DR
Mailing Address - Street 2:MEDICAL OFFICE-SUITE C
Mailing Address - City:WAYNESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:38485-2440
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:103 JV MANGUBAT DR
Practice Address - Street 2:MEDICAL OFFICE-SUITE C
Practice Address - City:WAYNESBORO
Practice Address - State:TN
Practice Address - Zip Code:38485-2440
Practice Address - Country:US
Practice Address - Phone:615-781-0013
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-22
Last Update Date:2011-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251S00000X
TN251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3376955Medicaid