Provider Demographics
NPI:1093920878
Name:LIFETIME RESOURCES, INC.
Entity Type:Organization
Organization Name:LIFETIME RESOURCES, INC.
Other - Org Name:GREENVILLE LOOP GROUP HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:T
Authorized Official - Last Name:THACKER, JR.
Authorized Official - Suffix:JR
Authorized Official - Credentials:PHD
Authorized Official - Phone:910-762-1189
Mailing Address - Street 1:1316 S. 16TH STREET
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-6422
Mailing Address - Country:US
Mailing Address - Phone:910-762-1189
Mailing Address - Fax:910-762-1301
Practice Address - Street 1:6100 GREENVILLE LOOP RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28409-2325
Practice Address - Country:US
Practice Address - Phone:910-762-1189
Practice Address - Fax:910-762-1301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2017-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3406453315P00000X, 320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3406453Medicaid