Provider Demographics
NPI:1558812461
Name:LIFECHOICES
Entity Type:Organization
Organization Name:LIFECHOICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-825-4161
Mailing Address - Street 1:225B MARKET ST
Mailing Address - Street 2:
Mailing Address - City:CRAMERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28032-1146
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6600 W WILKINSON BLVD
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:NC
Practice Address - Zip Code:28012-2796
Practice Address - Country:US
Practice Address - Phone:704-825-4161
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOLY ANGELS INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC036-310251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408854Medicaid
NC1619310851OtherSTATE FUNDED