Organization
LIFESPAN INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ROBIN DEVORE (VP CORPORATE COMPLIANCE AND PROGRAM)
(704) 944-5100
Entity
Organization
Contact information
Practice address
4806 FARM POND LN, CHARLOTTE, NC 28212-8558
(704) 536-7739
Mailing address
1511 SHOPTON RD, SUITE A, CHARLOTTE, NC 28217-3239
(704) 944-5100
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
MHL-060-1336
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
3408802
—
NC
Enumeration date
01/11/2017
Last updated
01/11/2017
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