Provider Demographics
NPI:1942377114
Name:EXCEL FOR LIFE, LLC
Entity Type:Organization
Organization Name:EXCEL FOR LIFE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:JERMAINE
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-205-0381
Mailing Address - Street 1:1730 CAROLINA AVE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-3315
Mailing Address - Country:US
Mailing Address - Phone:252-946-4243
Mailing Address - Fax:252-975-8049
Practice Address - Street 1:1730 CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-3315
Practice Address - Country:US
Practice Address - Phone:252-946-4243
Practice Address - Fax:252-975-8049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC007044322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children