Healthcare Provider Details

I. General information

NPI: 1063681120
Provider Name (Legal Business Name): LIFES RESTORATION HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2008
Last Update Date: 02/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 ROSEMONT AVE
HAMLET NC
28345-4764
US

IV. Provider business mailing address

108 ROSEMONT AVE
HAMLET NC
28345-4764
US

V. Phone/Fax

Practice location:
  • Phone: 910-557-5000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name: LAKRESHA MCLEAN
Title or Position: CEO
Credential:
Phone: 910-557-5000