Provider Demographics
NPI:1770007213
Name:LIFESPAN INCORPORATED
Entity Type:Organization
Organization Name:LIFESPAN INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP CORPORATE COMPLIANCE AND PROGRAM
Authorized Official - Prefix:
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEVORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-944-5100
Mailing Address - Street 1:1511 SHOPTON RD STE A
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-3240
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:532 PLEASANT VALLEY RD
Practice Address - Street 2:
Practice Address - City:MURPHY
Practice Address - State:NC
Practice Address - Zip Code:28906-2501
Practice Address - Country:US
Practice Address - Phone:704-944-5100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-26
Last Update Date:2017-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL020075251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health