Provider Demographics
NPI:1649515412
Name:KEYS 4 L.I.F.E.
Entity type:Organization
Organization Name:KEYS 4 L.I.F.E.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O.
Authorized Official - Prefix:MR
Authorized Official - First Name:DERRICK
Authorized Official - Middle Name:JEROME
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:SR
Authorized Official - Credentials:BS,QP
Authorized Official - Phone:910-817-7422
Mailing Address - Street 1:136 RAIDER RD
Mailing Address - Street 2:
Mailing Address - City:ROCKINGHAM
Mailing Address - State:NC
Mailing Address - Zip Code:28379-9609
Mailing Address - Country:US
Mailing Address - Phone:910-334-4390
Mailing Address - Fax:
Practice Address - Street 1:136 RAIDER RD
Practice Address - Street 2:
Practice Address - City:ROCKINGHAM
Practice Address - State:NC
Practice Address - Zip Code:28379-9609
Practice Address - Country:US
Practice Address - Phone:910-334-4390
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-05
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC000000Medicaid