1003021874 NPI number — LIFETIME RESOURCES, INC.

Table of content: (NPI 1003021874)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003021874 NPI number — LIFETIME RESOURCES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFETIME RESOURCES, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ECHO FARMS GROUP HOME
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003021874
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/07/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1316 S. 16TH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28401-6422
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-762-1189
Provider Business Mailing Address Fax Number:
910-762-1301

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
220 DORCHESTER PL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28412-7324
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-762-1189
Provider Business Practice Location Address Fax Number:
910-762-1301
Provider Enumeration Date:
05/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
THACKER, JR.
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
T.
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
910-762-1189

Provider Taxonomy Codes

  • Taxonomy code: 315P00000X , with the licence number:  3406452 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 320600000X , with the licence number: 3406452 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3406452 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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