Basic Information
| Provider Information | |||||||||
| NPI: | 1669717302 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIFT WELLNESS INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 JACKSON WALK PLAZA | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7314256900 | ||||||||
| FaxNumber: | 7314256915 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 JACKSON WALK PLAZA | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7314256900 | ||||||||
| FaxNumber: | 7314256915 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2012 | ||||||||
| LastUpdateDate: | 12/06/2012 | ||||||||
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| AuthorizedOfficialLastName: | PHILLIPS | ||||||||
| AuthorizedOfficialFirstName: | JAMA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7315121510 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | JACKSON MADISON COUNTY GENERAL HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.