1316083371 NPI number — LIFESPAN, INC.

Table of content: (NPI 1316083371)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316083371 NPI number — LIFESPAN, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFESPAN, 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:
Provider Other Organization Name Type Code:
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:
1316083371
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/05/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1511 SHOPTON RD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28217-3239
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-944-5100
Provider Business Mailing Address Fax Number:
704-944-5102

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1801 OAK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28269-4869
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-596-4135
Provider Business Practice Location Address Fax Number:
704-598-3634
Provider Enumeration Date:
01/29/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DEVORE
Authorized Official First Name:
ROBIN
Authorized Official Middle Name:
Authorized Official Title or Position:
VP CORPORATE COMPLIANCE/PROGRAM OPS
Authorized Official Telephone Number:
704-944-5100

Provider Taxonomy Codes

  • Taxonomy code: 251C00000X , with the licence number:  MHL-060-018 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 315P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 320600000X , with the licence number: MHL-060-018 , 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: 3408802 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".