Provider Demographics
NPI:1881891695
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:LCAS, LCSWA
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:27407-3709
Mailing Address - Country:US
Mailing Address - Phone:336-887-0708
Mailing Address - Fax:336-887-1085
Practice Address - Street 1:4003 GATWICK CT
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-8573
Practice Address - Country:US
Practice Address - Phone:336-697-5277
Practice Address - Fax:336-887-1085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-27
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL 041 699322D00000X
NC041-699320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603624Medicaid