Provider Demographics
NPI:1750692620
Name:LIFE ST. JOSEPH OF THE PINES, INC.
Entity type:Organization
Organization Name:LIFE ST. JOSEPH OF THE PINES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:DICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-429-7255
Mailing Address - Street 1:4900 RAEFORD RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3142
Mailing Address - Country:US
Mailing Address - Phone:910-483-4911
Mailing Address - Fax:910-483-4930
Practice Address - Street 1:4900 RAEFORD RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3142
Practice Address - Country:US
Practice Address - Phone:910-483-4911
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST JOSEPH OF THE PINES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-06-25
Last Update Date:2013-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCPENDING251T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization