Provider Demographics
NPI:1326186578
Name:A POSITIVE LIFE
Entity Type:Organization
Organization Name:A POSITIVE LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:910-223-7300
Mailing Address - Street 1:351 WAGONER DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-4608
Mailing Address - Country:US
Mailing Address - Phone:910-223-7300
Mailing Address - Fax:910-323-3206
Practice Address - Street 1:6033 CONCHO CT
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-2509
Practice Address - Country:US
Practice Address - Phone:910-480-2555
Practice Address - Fax:910-323-3206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL026742320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603408Medicaid