Healthcare Provider Details

I. General information

NPI: 1700290533
Provider Name (Legal Business Name): LIFE ENHANCEMENT SERVICES OF IL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2014
Last Update Date: 06/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 N MICHIGAN AVE STE 600
CHICAGO IL
60611-3777
US

IV. Provider business mailing address

9700 RESEARCH DR SUITE 111
CHARLOTTE NC
28262-8552
US

V. Phone/Fax

Practice location:
  • Phone: 704-342-9595
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. HERBERT GRAY
Title or Position: CEO/OWNER
Credential:
Phone: 704-342-9595