Healthcare Provider Details

I. General information

NPI: 1477174407
Provider Name (Legal Business Name): GARDEN OF LIFE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2020
Last Update Date: 08/13/2020
Certification Date: 08/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8339 FOX SWAMP RD
CHARLOTTE NC
28215-9011
US

IV. Provider business mailing address

8339 FOX SWAMP RD
CHARLOTTE NC
28215-9011
US

V. Phone/Fax

Practice location:
  • Phone: 980-309-6863
  • Fax:
Mailing address:
  • Phone: 845-728-9166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: DESHALL HILL
Title or Position: OWNER
Credential:
Phone: 890-309-6863