Healthcare Provider Details

I. General information

NPI: 1619013695
Provider Name (Legal Business Name): LIFESPAN, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 11/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

628 FLOWE DR
CHARLOTTE NC
28213-5607
US

IV. Provider business mailing address

1511 SHOPTON RD SUITE A
CHARLOTTE NC
28217-3239
US

V. Phone/Fax

Practice location:
  • Phone: 704-598-6002
  • Fax: 704-944-5102
Mailing address:
  • Phone: 704-944-5100
  • Fax: 704-944-5102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License NumberMHL-060-150
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberMHL-060-150
License Number StateNC

VIII. Authorized Official

Name: MS. ROBIN DEVORE
Title or Position: VP CORPORATE COMPLIANCE/PROGRAM OPS
Credential: BA
Phone: 704-944-5100