Healthcare Provider Details

I. General information

NPI: 1013261957
Provider Name (Legal Business Name): ENVISIONS OF LIFE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2012
Last Update Date: 03/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 CENTERVIEW DRIVE SUITE 110
GREENSBORO NC
27407-3709
US

IV. Provider business mailing address

5 CENTERVIEW DRIVE SUITE 110
GREENSBORO NC
27407-3079
US

V. Phone/Fax

Practice location:
  • Phone: 336-887-0708
  • Fax: 336-887-1085
Mailing address:
  • Phone: 336-887-0708
  • Fax: 336-887-1085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNC

VIII. Authorized Official

Name: TOMEKO MICHELLE MOORE
Title or Position: PRESIDENTE
Credential:
Phone: 336-887-0708