Healthcare Provider Details

I. General information

NPI: 1770721813
Provider Name (Legal Business Name): ENRICHMENT FOR LIFE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2009
Last Update Date: 01/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1138 DREW ST
DURHAM NC
27701-2702
US

IV. Provider business mailing address

4501 NEW BERN AVE SUITE 130-120
RALEIGH NC
27610-1549
US

V. Phone/Fax

Practice location:
  • Phone: 919-667-1580
  • Fax:
Mailing address:
  • Phone: 919-349-4206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberMHL-032-470
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberMHL-032-470
License Number StateNC

VIII. Authorized Official

Name: MRS. TERESA CELESTE MULLEN
Title or Position: EXECUTIVE DIRECTOR
Credential: LPN
Phone: 919-345-5847