Healthcare Provider Details

I. General information

NPI: 1063758282
Provider Name (Legal Business Name): MONTELISSA FULL LIFE RESOURCES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2012
Last Update Date: 12/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1008 CLARKVIEW ST SW
DECATUR AL
35601-6204
US

IV. Provider business mailing address

1008 CLARKVIEW ST SW
DECATUR AL
35601-6204
US

V. Phone/Fax

Practice location:
  • Phone: 256-686-1411
  • Fax:
Mailing address:
  • Phone: 256-686-1411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number
License Number State

VIII. Authorized Official

Name: MS. DENISE JOHNSON MASON
Title or Position: CEO
Credential:
Phone: 256-345-3996