Healthcare Provider Details

I. General information

NPI: 1497575948
Provider Name (Legal Business Name): HEALTH AND LIFE ORGANIZATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2024
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 STOCKTON BLVD STE 110
SACRAMENTO CA
95820-5492
US

IV. Provider business mailing address

3030 EXPLORER DR
SACRAMENTO CA
95827-2728
US

V. Phone/Fax

Practice location:
  • Phone: 916-642-1867
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateNULL

VIII. Authorized Official

Name: JERRY T BLIATOUT
Title or Position: CEO
Credential:
Phone: 916-642-1867