Lifetime Resources, Inc.

Primary specialty

Intellectual Disabilities Intermediate Care FacilityTaxonomy code 315P00000X

License

3406451 Issued in NC

Legal business name

LIFETIME RESOURCES, INC.

Practice address

6732 Myrtle Grove Rd
Wilmington, NC 28409-4804

Phone

(910) 762-1189

Fax

(910) 762-1301

NPI assigned

May 14, 2007

Last updated

Jul 7, 2017By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Robert T. Thacker, Jr. Jr., PH.D.

Title

Executive Director

Phone

(910) 762-1189

Specialties & licenses 2

Addresses

Other identifiers 1

Other names 1

• Myrtle Grove Group Home Other name

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1952516700. Details of each certification follow.

• CCN 34G101 Intermediate care facility for individuals with intellectual disabilities · Active · Name & address match · Details

Intermediate care facility for individuals with intellectual disabilities certification: CCN 34G101

Legal name

MYRTLE GROVE GROUP HOME

Certification status

Active

Provider type (POS)

Intermediate care facility for individuals with intellectual disabilities

Participating since

Nov 30, 1988

Last certification

Aug 6, 2025

Beds

6

Ownership / control type

Private (non-profit)

Most recent change of ownership

Aug 15, 2018

Facility address

6732 Myrtle Grove Road
Wilmington, NC 28409

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

Tax ID family

Echo Farms Group Home3 organizations share this tax ID, including this one

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

• Lifetime Resources, Inc.

  • Intellectual Disabilities Intermediate Care Facility
  • Wilmington, NC
  • NPI 1003021874
  NPD tax ID
• Lifetime Resources, Inc.

  • Intellectual Disabilities Intermediate Care Facility
  • Wilmington, NC
  • NPI 1093920878
  NPD tax ID

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1179100800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1499385600000",
    "number": "1952516700",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1316 S. 16TH STREET",
            "city": "WILMINGTON",
            "state": "NC",
            "postal_code": "284016422",
            "telephone_number": "910-762-1189",
            "fax_number": "910-762-1301"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "6732 MYRTLE GROVE RD",
            "city": "WILMINGTON",
            "state": "NC",
            "postal_code": "284094804",
            "telephone_number": "910-762-1189",
            "fax_number": "910-762-1301"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LIFETIME RESOURCES, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-05-14",
        "last_updated": "2017-07-07",
        "status": "A",
        "authorized_official_last_name": "THACKER, JR.",
        "authorized_official_first_name": "ROBERT",
        "authorized_official_middle_name": "T.",
        "authorized_official_title_or_position": "EXECUTIVE DIRECTOR",
        "authorized_official_telephone_number": "910-762-1189",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_name_suffix": "Jr.",
        "authorized_official_credential": "PH.D."
    },
    "taxonomies": [
        {
            "code": "315P00000X",
            "taxonomy_group": "",
            "desc": "Intermediate Care Facility, Intellectual Disabilities",
            "state": "NC",
            "license": "3406451",
            "primary": true
        },
        {
            "code": "320600000X",
            "taxonomy_group": "",
            "desc": "Residential Treatment Facility, Intellectual and/or Developmental Disabilities",
            "state": "NC",
            "license": "3406451",
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "3406451",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Myrtle Grove Group Home",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

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• Intellectual Disabilities Intermediate Care Facility in Wilmington, NC
• Providers in Wilmington, NC by specialty
• Intellectual Disabilities Intermediate Care Facility in North Carolina

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 7, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; facility enrollments, owners and changes of ownership; Provider of Services certification data.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.