Provider Demographics
NPI:1124262050
Name:A GOOD LIFE FAMILY CARE HOME
Entity type:Organization
Organization Name:A GOOD LIFE FAMILY CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:COLE
Authorized Official - Last Name:BALLENTINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-834-3966
Mailing Address - Street 1:4013 TRYON RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27606-4209
Mailing Address - Country:US
Mailing Address - Phone:919-834-3966
Mailing Address - Fax:919-834-3966
Practice Address - Street 1:4013 TRYON RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27606-4209
Practice Address - Country:US
Practice Address - Phone:919-834-3966
Practice Address - Fax:919-834-3966
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-22
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-092-106310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility