Healthcare Provider Details

I. General information

NPI: 1881891695
Provider Name (Legal Business Name): ENVISIONS OF LIFE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2007
Last Update Date: 03/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4003 GATWICK CT
GREENSBORO NC
27406-8573
US

IV. Provider business mailing address

5 CENTERVIEW DR. STE 110
GREENSBORO NC
27407-3709
US

V. Phone/Fax

Practice location:
  • Phone: 336-697-5277
  • 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 Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number041-699
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License NumberMHL 041 699
License Number StateNC

VIII. Authorized Official

Name: MRS. TOMEKO MOORE
Title or Position: PRESIDENT
Credential: LCAS, LCSWA
Phone: 336-887-0708