Provider Demographics
NPI:1114607637
Name:BACK 2 LYFE OUTREACH SERVICES, INC
Entity Type:Organization
Organization Name:BACK 2 LYFE OUTREACH SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LASHAUNA
Authorized Official - Middle Name:APRIL
Authorized Official - Last Name:GRIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:443-286-7850
Mailing Address - Street 1:109 STOCK LN
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-9720
Mailing Address - Country:US
Mailing Address - Phone:980-292-3213
Mailing Address - Fax:
Practice Address - Street 1:1914 J N PEASE PL
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-4504
Practice Address - Country:US
Practice Address - Phone:980-292-3213
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-19
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)