Provider Demographics
NPI:1013437540
Name:DESHALL'S GARDEN OF LIFE, LLC
Entity Type:Organization
Organization Name:DESHALL'S GARDEN OF LIFE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DESHALL
Authorized Official - Middle Name:MONIQUE
Authorized Official - Last Name:HILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:845-728-9166
Mailing Address - Street 1:415 BERKLEY HILL DR.
Mailing Address - Street 2:#1314
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-9720
Mailing Address - Country:US
Mailing Address - Phone:845-728-6166
Mailing Address - Fax:
Practice Address - Street 1:415 BERKLEY HILL DRIVE
Practice Address - Street 2:APT 1314
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262
Practice Address - Country:US
Practice Address - Phone:845-728-6166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DESHALL'S GARDEN OF LIFE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-06-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC253Z00000X, 310400000X, 320600000X, 320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No253Z00000XAgenciesIn Home Supportive Care
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities