Provider Demographics
NPI:1376927236
Name:LIFESPAN
Entity Type:Organization
Organization Name:LIFESPAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP CORPORATE COMPLIANCE/PROGRAM OPS
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVORE
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:704-944-5100
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 1:291 STEWART RD
Practice Address - Street 2:
Practice Address - City:ANDREWS
Practice Address - State:NC
Practice Address - Zip Code:28901-8603
Practice Address - Country:US
Practice Address - Phone:828-321-6034
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-10
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-020-068251C00000X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408802Medicaid