1336293794 NPI number — LIFE, INC.

Table of content: (NPI 1336293794)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336293794 NPI number — LIFE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFE, 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:
1336293794
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
117J VILLAGE RD NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LELAND
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28451-7413
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-371-0230
Provider Business Mailing Address Fax Number:
910-799-3680

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 CHEROKEE TRL
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:
28409-3407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-799-9517
Provider Business Practice Location Address Fax Number:
910-799-3680
Provider Enumeration Date:
01/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
VP OF BUSINESS OPERATIONS
Authorized Official Telephone Number:
919-778-1900

Provider Taxonomy Codes

  • Taxonomy code: 315P00000X , with the licence number:  MHL-065-040 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 340608W , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 944598 . This is a "STATE FACILITY ID" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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