Provider Demographics
NPI:1295935914
Name:LIFE FOUNDATIONS
Entity type:Organization
Organization Name:LIFE FOUNDATIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:WHITTED
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-572-0900
Mailing Address - Street 1:2314 S MIAMI BLVD
Mailing Address - Street 2:SUITE 156
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-5793
Mailing Address - Country:US
Mailing Address - Phone:919-572-0900
Mailing Address - Fax:919-572-0937
Practice Address - Street 1:2314 S MIAMI BLVD
Practice Address - Street 2:SUITE 156
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-5793
Practice Address - Country:US
Practice Address - Phone:919-572-0900
Practice Address - Fax:919-572-0937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300989Medicaid