Healthcare Provider Details

I. General information

NPI: 1619880994
Provider Name (Legal Business Name): LIFE MNT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16590 ROYAL POINCIANA CT
WESTON FL
33326-1743
US

IV. Provider business mailing address

16590 ROYAL POINCIANA CT
WESTON FL
33326-1743
US

V. Phone/Fax

Practice location:
  • Phone: 561-201-6237
  • Fax:
Mailing address:
  • Phone: 561-201-6237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name: JENNY GONZALEZ
Title or Position: MANAGER
Credential: LDN
Phone: 561-201-6237