Provider Demographics
NPI:1801937552
Name:LIFE ENRICHMENT CENTER OF CLEVELAND COUNTY, INC.
Entity type:Organization
Organization Name:LIFE ENRICHMENT CENTER OF CLEVELAND COUNTY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TONI
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMP
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:704-484-0405
Mailing Address - Street 1:110 LIFE ENRICHMENT BLVD
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28150-3689
Mailing Address - Country:US
Mailing Address - Phone:704-484-0405
Mailing Address - Fax:704-484-0406
Practice Address - Street 1:110 LIFE ENRICHMENT BLVD
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-3689
Practice Address - Country:US
Practice Address - Phone:704-484-0405
Practice Address - Fax:704-484-0406
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFE ENRICHMENT CENTER OF CLEVELAND COUNTY, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCDHHS251B00000X
251S00000X, 261QD1600X
NC385H00000X, 261QA0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408527Medicaid