Provider Demographics
NPI:1669705596
Name:EXCEL 4 LIFE, INC
Entity type:Organization
Organization Name:EXCEL 4 LIFE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:BA CRIMINAL JUSTICE
Authorized Official - Phone:252-205-0381
Mailing Address - Street 1:1730 CAROLINA AVE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-3315
Mailing Address - Country:US
Mailing Address - Phone:252-205-0381
Mailing Address - Fax:252-205-0381
Practice Address - Street 1:1730 CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-3315
Practice Address - Country:US
Practice Address - Phone:252-205-0381
Practice Address - Fax:252-205-0381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-10
Last Update Date:2009-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children