Provider Demographics
NPI:1275982688
Name:LIFESPAN
Entity Type:Organization
Organization Name:LIFESPAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF CORPORATE COMPLIANCE AND PROG
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-763-1887
Mailing Address - Street 1:1511 SHOPTON RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-3239
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:360 DUKE LODGE RD
Practice Address - Street 2:
Practice Address - City:MURPHY
Practice Address - State:NC
Practice Address - Zip Code:28906-5841
Practice Address - Country:US
Practice Address - Phone:828-557-0975
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL020073251C00000X
NCMHL-020-073251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251C00000XAgenciesDay Training, Developmentally Disabled Services