34D2122378 CLIA NUMBER - LIFE, INC - COKE AVENUE GROUP HOME

Laboratory Demographics

CLIA Number: 34D2122378

Facility Name: LIFE, INC - COKE AVENUE GROUP HOME

Facility Address:
255 COKE AVENUE
EDENTON, NC
ZIP 27932
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Facility Phone Number: 252 482-8121

Facility Type: Intermediate Care Facility for Mentally Retarded

Certificate Type: Waiver

NPI Number: 1154475515

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	34D2122378
LAB Type	Intermediate Care Facility for Mentally Retarded
Facility Name	LIFE, INC - COKE AVENUE GROUP HOME
Street	255 COKE AVENUE
City	EDENTON
State	NC
ZIP	27932
Phone	252 482-8121
CertificateType	4
CertificateEffectiveDate	11/28/2022
CertificateExpirationDate	11/27/2024
FacilityType	Waiver

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