Provider Demographics
NPI:1659349041
Name:HOUSE OF LIFE FAMILY PRACTICE PLLC
Entity Type:Organization
Organization Name:HOUSE OF LIFE FAMILY PRACTICE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:336-765-3430
Mailing Address - Street 1:1800 S HAWTHORNE RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4014
Mailing Address - Country:US
Mailing Address - Phone:336-765-3430
Mailing Address - Fax:336-765-3429
Practice Address - Street 1:1800 S HAWTHORNE RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4014
Practice Address - Country:US
Practice Address - Phone:336-765-3430
Practice Address - Fax:336-765-3429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-10
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89131Y7Medicaid
131Y7OtherBLUE CROSS BS
NC1033392774OtherINDIVIDUAL NPI
NC89131Y7Medicaid
NC89131Y7Medicaid
NC1033392774OtherINDIVIDUAL NPI
NC2349783Medicare PIN