Provider Demographics
NPI:1942354303
Name:LIFE, INC.
Entity Type:Organization
Organization Name:LIFE, INC.
Other - Org Name:LIFE, INC./KING STREET GROUP HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SENIOR VICE PRESIDENT/CFO
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-778-1900
Mailing Address - Street 1:PO BOX 446
Mailing Address - Street 2:
Mailing Address - City:HALIFAX
Mailing Address - State:NC
Mailing Address - Zip Code:27839-0446
Mailing Address - Country:US
Mailing Address - Phone:252-583-1984
Mailing Address - Fax:252-583-1615
Practice Address - Street 1:117 SOUTH KING STREET
Practice Address - Street 2:
Practice Address - City:HALIFAX
Practice Address - State:NC
Practice Address - Zip Code:27839-0446
Practice Address - Country:US
Practice Address - Phone:252-583-1984
Practice Address - Fax:252-583-1615
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFE, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-23
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-042-028315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC970428OtherSTATE FACILITY ID
NC340612AMedicaid