Provider Demographics
NPI:1750682357
Name:LIFE ENHANCEMENT SERVICES OF DC, LLC
Entity Type:Organization
Organization Name:LIFE ENHANCEMENT SERVICES OF DC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:704-342-9595
Mailing Address - Street 1:1328 SOUTHERN AVE SE
Mailing Address - Street 2:MEDICAL SERVICES BUILDING
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20032-4689
Mailing Address - Country:US
Mailing Address - Phone:202-562-6262
Mailing Address - Fax:
Practice Address - Street 1:1310 SOUTHERN AVE SE
Practice Address - Street 2:MEDICAL SERVICES BUILDING
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-4623
Practice Address - Country:US
Practice Address - Phone:202-562-6262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-12
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC050018500Medicaid