Provider Demographics
NPI:1902352123
Name:LIFE PRIMARY CARE CLINIC, PLLC
Entity Type:Organization
Organization Name:LIFE PRIMARY CARE CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:H
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:252-916-3645
Mailing Address - Street 1:PO BOX 87
Mailing Address - Street 2:
Mailing Address - City:GRIMESLAND
Mailing Address - State:NC
Mailing Address - Zip Code:27837-0087
Mailing Address - Country:US
Mailing Address - Phone:252-758-0602
Mailing Address - Fax:252-329-9002
Practice Address - Street 1:550 RIVER STREET
Practice Address - Street 2:
Practice Address - City:GRIMESLAND
Practice Address - State:NC
Practice Address - Zip Code:27837
Practice Address - Country:US
Practice Address - Phone:252-758-0602
Practice Address - Fax:252-329-9002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-28
Last Update Date:2016-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5005487363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7006027Medicaid