Provider Demographics
NPI:1437203890
Name:LIFE, INC.
Entity Type:Organization
Organization Name:LIFE, INC.
Other - Org Name:LIFE/RAVEN RIDGE GROUP HOME
Other - Org Type:Doing Business As
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 1:2609 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:919-778-1972
Practice Address - Street 1:4105 RAVEN RIDGE DR NW
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27896-9656
Practice Address - Country:US
Practice Address - Phone:252-291-8348
Practice Address - Fax:252-291-0812
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-098-011315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC340603HMedicaid
NC922436OtherSTATE FACILITY ID