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NPI Code Detail

MEDICARE: LIFE DOMAINS, LLC

MEDICARE: LIFE DOMAINS, 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
1251B00000XCase Management AgencyNC

General Provider Information

NPI Number : 1316191869
Entity Type Code : Organization
Provider Name (Legal Business Name) : LIFE DOMAINS, LLC
Provider Business Mailing Address
First Line : 1146 N CHURCH ST
Second Line : SUITE G
City : BURLINGTON
State : NC
Zip : 27217-2702
Country : US
Telephone Number : 336-269-4048
Fax Number :
Provider Business Practice Location Address
First Line : 1656 NORTH GLENCOE ROAD
Second Line :
City : BURLINGTON
State : NC
Zip : 27215
Country : US
Telephone Number : 336-269-4048
Fax Number :
Authorized Official
Title or Position : OWNER
Name : MS. TOYA STEPHENS
Credential :
Telephone Number : 336-269-4048
Provider Enumeration Date : 11/11/2008
Last Update Date : 11/11/2008

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