Basic Information
Provider Information | |||||||||
NPI: | 1548703457 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LIFEBRITE HOSPITAL GROUP OF STOKES, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | LIFEBRITE MEDICAL CENTER OF KING | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 402 W KING ST | ||||||||
Address2: |   | ||||||||
City: | KING | ||||||||
State: | NC | ||||||||
PostalCode: | 270219170 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3369839617 | ||||||||
FaxNumber: | 3369839791 | ||||||||
Practice Location | |||||||||
Address1: | 402 W KING ST | ||||||||
Address2: |   | ||||||||
City: | KING | ||||||||
State: | NC | ||||||||
PostalCode: | 270219170 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3369839617 | ||||||||
FaxNumber: | 3369839791 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/25/2016 | ||||||||
LastUpdateDate: | 09/07/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FLETCHER | ||||||||
AuthorizedOfficialFirstName: | CHRISTIAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 3365935311 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/07/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC0060X |   |   | N |   | Hospitals | General Acute Care Hospital | Critical Access | 261QC0050X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Critical Access Hospital |
ID Information
ID | Type | State | Issuer | Description | G557 | 01 | NC | MEDICARE PART B PTAN | OTHER | H0165 | 01 | NC | HOSPITAL LICENSURE | OTHER |