Provider Demographics
NPI:1114052123
Name:NEW-LITE LIVING CHOICES TUNSTALL MARVIN GEN PTR
Entity Type:Organization
Organization Name:NEW-LITE LIVING CHOICES TUNSTALL MARVIN GEN PTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:FOLTZ
Authorized Official - Last Name:CAHOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-906-8893
Mailing Address - Street 1:416 MCCULLOUGH DR
Mailing Address - Street 2:SUITE 125
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-4385
Mailing Address - Country:US
Mailing Address - Phone:704-547-1900
Mailing Address - Fax:
Practice Address - Street 1:3634 VEST MILL RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-2910
Practice Address - Country:US
Practice Address - Phone:704-547-1900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8300407101YM0800X, 251B00000X, 251S00000X
NC6603599320800000X
NC6603600320800000X
NC6603994320800000X
320800000X
NC6604265320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300407Medicaid
NC8300407HMedicaid
NC8300407GMedicaid