Provider Demographics
NPI:1366811267
Name:CELEBRATE LIFE WELLNESS
Entity type:Organization
Organization Name:CELEBRATE LIFE WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:
Authorized Official - Last Name:GAURON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-376-5433
Mailing Address - Street 1:7750 W CRESTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-3000
Mailing Address - Country:US
Mailing Address - Phone:208-376-5433
Mailing Address - Fax:
Practice Address - Street 1:7750 W CRESTWOOD DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-3000
Practice Address - Country:US
Practice Address - Phone:208-376-5433
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-21
Last Update Date:2015-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDC0610305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization