MEDICARE: LIFESPAN INCORPORATED

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1144717018
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFESPAN INCORPORATED

Provider Business Mailing Address
First Line	:	1511 SHOPTON RD STE A
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28217-3240
Country	:	US
Telephone Number	:	704-763-1887
Fax Number	:

Provider Business Practice Location Address
First Line	:	3529 HATWYNN RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-1329
Country	:	US
Telephone Number	:	704-944-5100
Fax Number	:

Authorized Official
Title or Position	:	VP CORPORATE COMPLIANCE AND OPERATI
Name	:	ROBIN DEVORE
Credential	:
Telephone Number	:	704-944-5100

Provider Enumeration Date	:	04/17/2018
Last Update Date	:	06/16/2018

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Directions to “LIFESPAN INCORPORATED ” Practice Location

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