MEDICARE: WHOLE LIFE DISTRIBUTORS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	364SH0200X	Home Health Clinical Nurse Specialist
2	364SL0600X	Long-Term Care Clinical Nurse Specialist
3	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1407418981
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WHOLE LIFE DISTRIBUTORS

Provider Business Mailing Address
First Line	:	1055 NW 187TH AVENUE
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33029
Country	:	US
Telephone Number	:	954-305-4309
Fax Number	:

Provider Business Practice Location Address
First Line	:	1055 NW 187TH AVENUE
Second Line	:
City	:	PEMBROKE PINES
State	:	FL
Zip	:	33029
Country	:	US
Telephone Number	:	954-305-4309
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	IEGEIA NOEL
Credential	:
Telephone Number	:	954-305-4309

Provider Enumeration Date	:	07/03/2019
Last Update Date	:	07/03/2019

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