Provider Demographics
NPI:1104179555
Name:ENVISIONS OF LIFE LLC
Entity Type:Organization
Organization Name:ENVISIONS OF LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TOMEKO
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-887-0708
Mailing Address - Street 1:5 CENTERVIEW DR.
Mailing Address - Street 2:SUITE 110
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-3709
Mailing Address - Country:US
Mailing Address - Phone:336-887-0708
Mailing Address - Fax:336-887-1085
Practice Address - Street 1:5 CENTERVIEW DRIVE
Practice Address - Street 2:SUITE 110
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-3709
Practice Address - Country:US
Practice Address - Phone:336-887-0708
Practice Address - Fax:336-887-1085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-23
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101YP2500X, 251S00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6006285Medicaid