Provider Demographics
NPI:1124046198
Name:LIFE ENHANCEMENT MEDICAL SERVICES PLLC
Entity Type:Organization
Organization Name:LIFE ENHANCEMENT MEDICAL SERVICES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:PAVELOCK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-838-0516
Mailing Address - Street 1:2632 FINES CREEK DR
Mailing Address - Street 2:
Mailing Address - City:STATESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28625-4441
Mailing Address - Country:US
Mailing Address - Phone:704-838-0516
Mailing Address - Fax:704-838-0565
Practice Address - Street 1:190 COMMERCE BLVD
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28625-8526
Practice Address - Country:US
Practice Address - Phone:704-838-0516
Practice Address - Fax:704-838-0565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5904288Medicaid
NC5904288Medicaid
NCDD2965Medicare PIN
NC5904288Medicaid