Provider Demographics
NPI:1881788818
Name:ENVISIONS OF LIFE LLC
Entity type:Organization
Organization Name:ENVISIONS OF LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:TOMEKO
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-887-0708
Mailing Address - Street 1:5 CENTERVIEW DR
Mailing Address - Street 2:STE 110
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27407-3724
Mailing Address - Country:US
Mailing Address - Phone:336-887-0708
Mailing Address - Fax:336-887-1085
Practice Address - Street 1:5 CENTERVIEW DR.
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27407-3709
Practice Address - Country:US
Practice Address - Phone:336-887-0708
Practice Address - Fax:336-887-1085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
NC101YM0800X, 363LP0808X, 251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251B00000XAgenciesCase ManagementGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8301518Medicaid
NC8301518AMedicaid