=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972188100
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JL MASTERLIFE INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2021
-----------------------------------------------------
Last Update Date | 03/09/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1036 YEOPIM RD
-----------------------------------------------------
City | EDENTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27932-9417
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-486-8685
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 N BROAD ST # 89
-----------------------------------------------------
City | EDENTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27932-1988
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-486-8685
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/PRESIDENT
-----------------------------------------------------
Name | SONDRA COFIELD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 252-486-8685
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------