Provider Demographics
NPI:1285826503
Name:THE DOOR OF LIFE RESIDENTIAL SERVICES
Entity Type:Organization
Organization Name:THE DOOR OF LIFE RESIDENTIAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:HARVEY
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-420-3195
Mailing Address - Street 1:1505 BRAMBER PL
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29527-3177
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:227 CONSTITUTION WAY
Practice Address - Street 2:
Practice Address - City:CAMERON
Practice Address - State:NC
Practice Address - Zip Code:28326-9296
Practice Address - Country:US
Practice Address - Phone:919-499-2419
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-10
Last Update Date:2007-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL043069320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities