Provider Demographics
NPI:1770716235
Name:NEW LIFE FOUNDATIONS
Entity type:Organization
Organization Name:NEW LIFE FOUNDATIONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:LESLIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BREWSTER
Authorized Official - Suffix:
Authorized Official - Credentials:CM/QP
Authorized Official - Phone:919-672-0751
Mailing Address - Street 1:614 NORTH MADISION BLVD
Mailing Address - Street 2:
Mailing Address - City:ROXBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27573-4636
Mailing Address - Country:US
Mailing Address - Phone:919-672-0751
Mailing Address - Fax:
Practice Address - Street 1:5021 MILLER DR
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-1877
Practice Address - Country:US
Practice Address - Phone:919-672-0751
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-01
Last Update Date:2009-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1639338395Medicaid