MEDICARE: LIVING IN FULL EXCELLENCE

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

General Provider Information

NPI Number	:	1821444191
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIVING IN FULL EXCELLENCE

Provider Business Mailing Address
First Line	:	1220 NORTH ST
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28301-4413
Country	:	US
Telephone Number	:	910-853-2184
Fax Number	:

Provider Business Practice Location Address
First Line	:	1220 NORTH ST
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28301-4413
Country	:	US
Telephone Number	:	910-853-2184
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MS. LATASHA MICHELLE BETHEA
Credential	:	MS, LCAS-A
Telephone Number	:	910-853-2184

Provider Enumeration Date	:	05/05/2016
Last Update Date	:	05/05/2016

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Directions to “LIVING IN FULL EXCELLENCE ” Practice Location

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