Provider Demographics
NPI:1366729048
Name:REDESIGNING LIFE OF N.C.,LL
Entity type:Organization
Organization Name:REDESIGNING LIFE OF N.C.,LL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHANDRA
Authorized Official - Middle Name:REVIS
Authorized Official - Last Name:PEGUES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-363-4122
Mailing Address - Street 1:PO BOX 683
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27894-0683
Mailing Address - Country:US
Mailing Address - Phone:252-363-4122
Mailing Address - Fax:252-296-0033
Practice Address - Street 1:806 TARBORO ST W
Practice Address - Street 2:SUITE A
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-4771
Practice Address - Country:US
Practice Address - Phone:252-363-4122
Practice Address - Fax:252-296-0033
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HARVEST CARE OF N.C., LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-098-173261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health