=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013459643
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POSITIVE LIFE STYLES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/14/2016
-----------------------------------------------------
Last Update Date | 11/14/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4805 GREEN WING RD
-----------------------------------------------------
City | WILSON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27893-8142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-281-3967
-----------------------------------------------------
Fax | 252-674-7060
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4805 GREEN WING RD
-----------------------------------------------------
City | WILSON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27893-8142
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-281-3967
-----------------------------------------------------
Fax | 252-674-7060
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | IRIS H REID
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 252-281-3967
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number | FCL098033
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------