Provider Demographics
NPI:1851888721
Name:LIFESPAN INCORPORATED
Entity Type:Organization
Organization Name:LIFESPAN INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP CORPORATE COMPLIANCE AND OPERATI
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 1:4322 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:ANDREWS
Practice Address - State:NC
Practice Address - Zip Code:28901-8114
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:2018-04-17
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408802Medicaid