Organization
LIFETIME RESOURCES, INC.
Active
Other names
Myrtle Grove Group Home
Organization subpart
No
Provider details
NPI number
Authorized official
DR. ROBERT T. THACKER, JR. JR. PH.D. (EXECUTIVE DIRECTOR)
(910) 762-1189
Entity
Organization
Contact information
Practice address
6732 MYRTLE GROVE RD, WILMINGTON, NC 28409-4804
(910) 762-1189
(910) 762-1301
Mailing address
1316 S. 16TH STREET, WILMINGTON, NC 28401-6422
(910) 762-1189
(910) 762-1301
Taxonomy
Speciality
Code
Description
License number
State
315P00000X
Intellectual Disabilities Intermediate Care Facility
Primary
3406451
NC
320600000X
Intellectual and/or Developmental Disabilities Residential Treatment Facility
3406451
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
3406451
—
NC
Enumeration date
05/14/2007
Last updated
07/07/2017
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