=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255538039
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENVISIONS OF LIFE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4003 GATWICK CT
-----------------------------------------------------
City | GREENSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27406-8573
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-697-5277
-----------------------------------------------------
Fax | 336-697-3156
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 204 KELLY PL
-----------------------------------------------------
City | HIGH POINT
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27262-2609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-887-0708
-----------------------------------------------------
Fax | 336-887-1085
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. TOMEKO MICHELLE MOORE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 336-887-0708
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------