Provider Demographics
NPI:1366958902
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 1:2609 ROYALL AVE
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-8615
Mailing Address - Country:US
Mailing Address - Phone:919-778-1900
Mailing Address - Fax:919-778-1972
Practice Address - Street 1:706 S MCDANIEL ST
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:NC
Practice Address - Zip Code:27823-1757
Practice Address - Country:US
Practice Address - Phone:252-445-1590
Practice Address - Fax:252-445-1592
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-12-19
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-042-067251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408694Medicaid