Provider Demographics
NPI:1255815981
Name:WELLNESS LIFE CENTER LLC
Entity type:Organization
Organization Name:WELLNESS LIFE CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:M
Authorized Official - Last Name:ODUM
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:229-397-5433
Mailing Address - Street 1:1842 US HIGHWAY 84 W
Mailing Address - Street 2:
Mailing Address - City:CAIRO
Mailing Address - State:GA
Mailing Address - Zip Code:39827-4224
Mailing Address - Country:US
Mailing Address - Phone:229-397-5433
Mailing Address - Fax:229-377-0930
Practice Address - Street 1:1842 US HIGHWAY 84 W
Practice Address - Street 2:
Practice Address - City:CAIRO
Practice Address - State:GA
Practice Address - Zip Code:39827-4224
Practice Address - Country:US
Practice Address - Phone:229-377-2002
Practice Address - Fax:229-377-0930
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-19
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty