Provider Demographics
NPI:1255507992
Name:NEW LITE LIVING CHOICES
Entity Type:Organization
Organization Name:NEW LITE LIVING CHOICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-771-0456
Mailing Address - Street 1:PO BOX 1310
Mailing Address - Street 2:SUITE 5
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28026-1310
Mailing Address - Country:US
Mailing Address - Phone:704-771-0456
Mailing Address - Fax:
Practice Address - Street 1:349 COPPERFIELD BLVD NE
Practice Address - Street 2:SUITE 5
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2408
Practice Address - Country:US
Practice Address - Phone:704-771-0456
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-02
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300407Medicaid