Healthcare Provider Details

I. General information

NPI: 1003021874
Provider Name (Legal Business Name): LIFETIME RESOURCES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 07/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 DORCHESTER PL
WILMINGTON NC
28412-7324
US

IV. Provider business mailing address

1316 S. 16TH STREET
WILMINGTON NC
28401-6422
US

V. Phone/Fax

Practice location:
  • Phone: 910-762-1189
  • Fax: 910-762-1301
Mailing address:
  • Phone: 910-762-1189
  • Fax: 910-762-1301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License Number3406452
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number3406452
License Number StateNC

VIII. Authorized Official

Name: DR. ROBERT T. THACKER, JR.
Title or Position: EXECUTIVE DIRECTOR
Credential: PH.D.
Phone: 910-762-1189