Provider Demographics
NPI:1972700763
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 1:307 S SWING RD STE 5
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27409-2073
Mailing Address - Country:US
Mailing Address - Phone:336-887-0708
Mailing Address - Fax:336-887-1085
Practice Address - Street 1:420 GULLEY ST
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27530-5045
Practice Address - Country:US
Practice Address - Phone:336-887-0708
Practice Address - Fax:336-887-1085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL 041 179322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6604062Medicaid