Provider Demographics
NPI:1891992673
Name:ENVISIONS OF LIFE LLC
Entity Type:Organization
Organization Name:ENVISIONS OF LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:TOMEKO
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-887-0708
Mailing Address - Street 1:204 KELLY PL
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27262-2609
Mailing Address - Country:US
Mailing Address - Phone:336-887-0708
Mailing Address - Fax:336-887-1085
Practice Address - Street 1:218 N MCPHERSON CHURCH RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-4495
Practice Address - Country:US
Practice Address - Phone:910-323-6002
Practice Address - Fax:910-323-6003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
NC251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase Management
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301519BMedicaid
NC8301519GMedicaid
NC8301519Medicaid
NC8301519AMedicaid
NC5950233Medicaid
NC8301519Medicaid