Provider Demographics
NPI:1548561483
Name:LIFESPAN, INC.
Entity Type:Organization
Organization Name:LIFESPAN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:LEIGH
Authorized Official - Middle Name:
Authorized Official - Last Name:DERBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-944-5100
Mailing Address - Street 1:200 CLANTON RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-1446
Mailing Address - Country:US
Mailing Address - Phone:704-944-5100
Mailing Address - Fax:704-944-5102
Practice Address - Street 1:908 MCCLELLAN PL
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27409-8929
Practice Address - Country:US
Practice Address - Phone:336-852-1495
Practice Address - Fax:336-855-9994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-09
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-041-508251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8702247Medicaid