Healthcare Provider Details

I. General information

NPI: 1114607637
Provider Name (Legal Business Name): BACK 2 LYFE OUTREACH SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2023
Last Update Date: 07/27/2023
Certification Date: 07/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1914 J N PEASE PL
CHARLOTTE NC
28262-4504
US

IV. Provider business mailing address

109 STOCK LN
MOORESVILLE NC
28115-9720
US

V. Phone/Fax

Practice location:
  • Phone: 980-292-3213
  • Fax:
Mailing address:
  • Phone: 980-292-3213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MRS. LASHAUNA APRIL GRIER
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 443-286-7850