Provider Demographics
NPI:1356481220
Name:LIFE, INC.
Entity Type:Organization
Organization Name:LIFE, INC.
Other - Org Name:WICKHAM ROAD FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF CONTRACT SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-778-1900
Mailing Address - Street 1:2609 ROYALL AVE
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-8615
Mailing Address - Country:US
Mailing Address - Phone:919-778-1900
Mailing Address - Fax:919-778-2920
Practice Address - Street 1:258 WICKHAM RD
Practice Address - Street 2:
Practice Address - City:SHILOH
Practice Address - State:NC
Practice Address - Zip Code:27974-7222
Practice Address - Country:US
Practice Address - Phone:252-336-4142
Practice Address - Fax:252-336-2372
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-08
Last Update Date:2017-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-015-004311ZA0620X, 343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7805689Medicaid