34D0994169 CLIA NUMBER - LIFE INC- GREEN TEE GROUP HOME

Laboratory Demographics

CLIA Number: 34D0994169

Facility Name: LIFE INC- GREEN TEE GROUP HOME

Facility Address:
1320 GREEN TEE LANE
ROCKY MOUNT, NC
ZIP 27804
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Facility Phone Number: 252 972-6975

Facility Type: Intermediate Care Facility for Mentally Retarded

Certificate Type: Waiver

NPI Number: 1386798163

Taxonomy: 315P00000X - Intermediate Care Facility, Intellectual Disabilities
An intermediate care facility providing services for individuals with intellectual disabilities.

CLIA Record

Field Name	Field Value
CLIA Number	34D0994169
LAB Type	Intermediate Care Facility for Mentally Retarded
Facility Name	LIFE INC- GREEN TEE GROUP HOME
Street	1320 GREEN TEE LANE
City	ROCKY MOUNT
State	NC
ZIP	27804
Phone	252 972-6975
CertificateType	4
CertificateEffectiveDate	12/6/2023
CertificateExpirationDate	12/5/2025
FacilityType	Waiver

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This page was last updated on: 4/23/2024