Provider Demographics
NPI:1124213343
Name:LIFESPAN, INC.
Entity Type:Organization
Organization Name:LIFESPAN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:DAVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CLONINGER
Authorized Official - Suffix:
Authorized Official - Credentials:BA, MA
Authorized Official - Phone:704-944-5100
Mailing Address - Street 1:200 CLANTON RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-1304
Mailing Address - Country:US
Mailing Address - Phone:704-944-5100
Mailing Address - Fax:704-944-5102
Practice Address - Street 1:200 CLANTON RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-1304
Practice Address - Country:US
Practice Address - Phone:704-944-5100
Practice Address - Fax:704-944-5102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-060-209251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300492GMedicaid