Provider Demographics
NPI:1336293794
Name:LIFE, INC.
Entity Type:Organization
Organization Name:LIFE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF BUSINESS OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-778-1900
Mailing Address - Street 1:117J VILLAGE RD NE
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-7413
Mailing Address - Country:US
Mailing Address - Phone:910-371-0230
Mailing Address - Fax:910-799-3680
Practice Address - Street 1:105 CHEROKEE TRL
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28409-3407
Practice Address - Country:US
Practice Address - Phone:910-799-9517
Practice Address - Fax:910-799-3680
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-23
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-065-040315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC340608WMedicaid
NC944598OtherSTATE FACILITY ID