Basic Information
| Provider Information | |||||||||
| NPI: | 1033357009 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WELLNESS 4 LIFE INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 170084 | ||||||||
| Address2: | |||||||||
| City: | HIALEAH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330170084 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543676192 | ||||||||
| FaxNumber: | 9543429624 | ||||||||
| Practice Location | |||||||||
| Address1: | 9680 PINES BLVD | ||||||||
| Address2: | N/A | ||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330246246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543676192 | ||||||||
| FaxNumber: | 9543429624 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2009 | ||||||||
| LastUpdateDate: | 10/20/2016 | ||||||||
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| AuthorizedOfficialLastName: | ROACH | ||||||||
| AuthorizedOfficialFirstName: | ELAINE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 9543676192 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133N00000X | ND4061 | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Dietary & Nutritional Service Providers | Nutritionist |
No ID Information.