Provider Demographics
NPI:1982910634
Name:LIFE ENHANCEMENT SERVICES
Entity type:Organization
Organization Name:LIFE ENHANCEMENT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:980-265-1064
Mailing Address - Street 1:9700 RESEARCH DR
Mailing Address - Street 2:SUITE 111
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-8552
Mailing Address - Country:US
Mailing Address - Phone:980-265-1064
Mailing Address - Fax:
Practice Address - Street 1:455 RAST ST
Practice Address - Street 2:SUITE A
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-2579
Practice Address - Country:US
Practice Address - Phone:704-560-4332
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-19
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC109BHSMedicaid