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General NPI Number Information
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NPI Number | 1003965781
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Entity Type | Organization
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Legal Business Name | LIFESPAN, INC.
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Dates
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Enumeration Date | 01/10/2007
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Last Update Date | 11/04/2016
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Provider Practice Location Address
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Address Line | 302 W BROAD ST
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City | STATESVILLE
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State | NC
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Zip | 28677-5260
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Country | US
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Telephone | 704-872-8579
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Fax | 704-872-5272
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Provider Business Mailing Address
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Address Line | 1511 SHOPTON RD SUITE A
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City | CHARLOTTE
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State | NC
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Zip | 28217-3239
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Country | US
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Telephone | 704-944-5100
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Fax | 704-944-5102
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Authorized Official
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Title or Position | VP CORPORATE COMPLIANCE/PROGRAM OPS
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Name | ROBIN DEVORE
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Credential | BA
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Telephone | 704-944-5100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251C00000X
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Taxonomy Name | Developmentally Disabled Services Day Training Agency
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License Number | 49000254
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License Number State | NC
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