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General NPI Number Information
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NPI Number | 1386195840
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Entity Type | Organization
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Legal Business Name | ENVISIONS OF LIFE LLC
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Dates
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Enumeration Date | 10/20/2016
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Last Update Date | 09/01/2017
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Provider Practice Location Address
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Address Line | 449 W MAIN ST
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City | JONESVILLE
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State | NC
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Zip | 28642-2130
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Country | US
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Telephone | 336-887-0708
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Fax | 336-887-1085
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Provider Business Mailing Address
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Address Line | 5 CENTERVIEW DR STE 110
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City | GREENSBORO
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State | NC
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Zip | 27407-3709
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Country | US
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Telephone | 336-887-0708
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Fax | 336-887-1085
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Authorized Official
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Title or Position | PRESIDENT
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Name | MRS. TOMEKO M MOORE
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Credential | LCAS, LCSWA
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Telephone | 336-887-0708
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number | 099-029
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License Number State | NC
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