MEDICARE: ENVISIONS OF LIFE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner		NC
2	101YM0800X	Mental Health Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1013261957
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ENVISIONS OF LIFE LLC

Provider Business Mailing Address
First Line	:	5 CENTERVIEW DRIVE
Second Line	:	SUITE 110
City	:	GREENSBORO
State	:	NC
Zip	:	27407-3079
Country	:	US
Telephone Number	:	336-887-0708
Fax Number	:	336-887-1085

Provider Business Practice Location Address
First Line	:	5 CENTERVIEW DRIVE
Second Line	:	SUITE 110
City	:	GREENSBORO
State	:	NC
Zip	:	27407-3709
Country	:	US
Telephone Number	:	336-887-0708
Fax Number	:	336-887-1085

Authorized Official
Title or Position	:	PRESIDENTE
Name	:	TOMEKO MICHELLE MOORE
Credential	:
Telephone Number	:	336-887-0708

Provider Enumeration Date	:	10/30/2012
Last Update Date	:	03/25/2015

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Directions to “ENVISIONS OF LIFE LLC ” Practice Location

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