Provider Demographics
NPI:1619013695
Name:LIFESPAN, INC.
Entity Type:Organization
Organization Name:LIFESPAN, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP CORPORATE COMPLIANCE/PROGRAM OPS
Authorized Official - Prefix:MS
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:704-944-5100
Mailing Address - Fax:704-944-5102
Practice Address - Street 1:628 FLOWE DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28213-5607
Practice Address - Country:US
Practice Address - Phone:704-598-6002
Practice Address - Fax:704-944-5102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-060-150251C00000X, 320600000X
315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408802Medicaid