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General NPI Number Information
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NPI Number | 1679621973
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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 | 01/05/2007
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Last Update Date | 06/03/2013
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Provider Practice Location Address
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Address Line | 908 MCCLELLAN PL
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City | GREENSBORO
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State | NC
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Zip | 27409-8929
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Country | US
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Telephone | 336-883-0111
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Fax | 336-883-0031
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Provider Business Mailing Address
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Address Line | 200 CLANTON RD
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City | CHARLOTTE
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State | NC
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Zip | 28217-1304
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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 | CEO/PRESIDENT
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Name | MS. DAVAN CLONINGER
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Credential | BA,MA
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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 | MHL-041-510
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License Number State | NC
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