MEDICARE: LIFE DOMAINS, LLC

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	251B00000X	Case Management Agency		NC

General Provider Information

NPI Number	:	1316191869
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE DOMAINS, LLC

Provider Business Mailing Address
First Line	:	1146 N CHURCH ST
Second Line	:	SUITE G
City	:	BURLINGTON
State	:	NC
Zip	:	27217-2702
Country	:	US
Telephone Number	:	336-269-4048
Fax Number	:

Provider Business Practice Location Address
First Line	:	1656 NORTH GLENCOE ROAD
Second Line	:
City	:	BURLINGTON
State	:	NC
Zip	:	27215
Country	:	US
Telephone Number	:	336-269-4048
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. TOYA STEPHENS
Credential	:
Telephone Number	:	336-269-4048

Provider Enumeration Date	:	11/11/2008
Last Update Date	:	11/11/2008

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