Provider Demographics
NPI:1295158699
Name:LIFE ENRICHMENT AND WELLNESS SERVICES
Entity type:Organization
Organization Name:LIFE ENRICHMENT AND WELLNESS SERVICES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CARLOS
Authorized Official - Middle Name:
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-949-3184
Mailing Address - Street 1:608 STONECREST DRIVE
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052
Mailing Address - Country:US
Mailing Address - Phone:678-949-3184
Mailing Address - Fax:
Practice Address - Street 1:608 STONECREST DRIVE
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052
Practice Address - Country:US
Practice Address - Phone:678-949-3184
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BCMM HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-01-22
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA006581251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health