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General NPI Number Information
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NPI Number | 1003021874
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Entity Type | Organization
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Legal Business Name | LIFETIME RESOURCES, INC.
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Dates
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Enumeration Date | 05/14/2007
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Last Update Date | 07/07/2017
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Provider Practice Location Address
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Address Line | 220 DORCHESTER PL
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City | WILMINGTON
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State | NC
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Zip | 28412-7324
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Country | US
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Telephone | 910-762-1189
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Fax | 910-762-1301
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Provider Business Mailing Address
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Address Line | 1316 S. 16TH STREET
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City | WILMINGTON
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State | NC
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Zip | 28401-6422
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Country | US
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Telephone | 910-762-1189
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Fax | 910-762-1301
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | DR. ROBERT T. THACKER, JR.
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Credential | PH.D.
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Telephone | 910-762-1189
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320600000X
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Taxonomy Name | Intellectual and/or Developmental Disabilities Residential Treatment Facility
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License Number | 3406452
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 315P00000X
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Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
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License Number | 3406452
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License Number State | NC
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