Provider Demographics
NPI:1225373467
Name:LIFE LINE COMMUNITY OUTREACH SERVICES
Entity Type:Organization
Organization Name:LIFE LINE COMMUNITY OUTREACH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/ OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ERNESTINE
Authorized Official - Middle Name:K
Authorized Official - Last Name:JULUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-744-5446
Mailing Address - Street 1:10705 NED CT
Mailing Address - Street 2:21
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-9152
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10705 NED CT
Practice Address - Street 2:21
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-9152
Practice Address - Country:US
Practice Address - Phone:919-744-5446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-28
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)