Provider Demographics
NPI:1275559759
Name:THERAPEUTIC LIFE CENTER, INC.
Entity Type:Organization
Organization Name:THERAPEUTIC LIFE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OCCUPATIONAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:JEANNE
Authorized Official - Middle Name:C
Authorized Official - Last Name:ROSAL
Authorized Official - Suffix:
Authorized Official - Credentials:OTR/L
Authorized Official - Phone:252-830-0245
Mailing Address - Street 1:102 EASTBROOK DRIVE
Mailing Address - Street 2:B AND C
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-4320
Mailing Address - Country:US
Mailing Address - Phone:252-830-0245
Mailing Address - Fax:252-830-0247
Practice Address - Street 1:102 EASTBROOK DR
Practice Address - Street 2:SUITE C
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-4320
Practice Address - Country:US
Practice Address - Phone:252-830-0245
Practice Address - Fax:252-830-0247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC012XUOtherBCBS-OT & PT SERVICES
NC7211029Medicaid
NC2504079Medicare ID - Type UnspecifiedPT SERVICES
NC012XUOtherBCBS-OT & PT SERVICES