Provider Demographics
NPI:1215081021
Name:LIFE, INC.
Entity type:Organization
Organization Name:LIFE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP OF BUSINESS OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-778-1900
Mailing Address - Street 1:PO BOX 446
Mailing Address - Street 2:
Mailing Address - City:HALIFAX
Mailing Address - State:NC
Mailing Address - Zip Code:27839-0446
Mailing Address - Country:US
Mailing Address - Phone:252-537-4686
Mailing Address - Fax:252-583-1615
Practice Address - Street 1:28 WOOD GLEN RD
Practice Address - Street 2:
Practice Address - City:ROANOKE RAPIDS
Practice Address - State:NC
Practice Address - Zip Code:27870-6285
Practice Address - Country:US
Practice Address - Phone:252-537-4686
Practice Address - Fax:252-583-1615
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-22
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-042-009315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC922027OtherSTATE FACILITY ID
NC3416196Medicaid