Provider Demographics
NPI:1801067970
Name:LIFE ENHANCEMENT SERVICES
Entity type:Organization
Organization Name:LIFE ENHANCEMENT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DEMETRIUS
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-241-9722
Mailing Address - Street 1:500 E MOREHEAD ST
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-2616
Mailing Address - Country:US
Mailing Address - Phone:704-342-9595
Mailing Address - Fax:
Practice Address - Street 1:203 CAMPBELL DR
Practice Address - Street 2:
Practice Address - City:TUSKEGEE
Practice Address - State:AL
Practice Address - Zip Code:36083-2315
Practice Address - Country:US
Practice Address - Phone:704-241-9722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-17
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALUNSPECIFIEDMedicaid