Provider Demographics
NPI:1477174407
Name:GARDEN OF LIFE, INC
Entity Type:Organization
Organization Name:GARDEN OF LIFE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DESHALL
Authorized Official - Middle Name:
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:890-309-6863
Mailing Address - Street 1:8339 FOX SWAMP RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-9011
Mailing Address - Country:US
Mailing Address - Phone:845-728-9166
Mailing Address - Fax:
Practice Address - Street 1:8339 FOX SWAMP RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-9011
Practice Address - Country:US
Practice Address - Phone:980-309-6863
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-30
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental IllnessGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC171M00000XMedicaid
NC225I0000XMedicaid
NC251S00000XMedicaid
NC106S0000XMedicaid
NC251B00000XMedicaid
NC302R0000XMedicaid
NC1041I0000XMedicaid
NC22420000XMedicaid
NC2260000XMedicaid
NC305R0000XMedicaid
NC363L0000XMedicaid
NC302F0000XMedicaid
NC106H0000XMedicaid
NC175T0000XMedicaid
NC164W0000XMedicaid