Healthcare Provider Details

I. General information

NPI: 1063876407
Provider Name (Legal Business Name): MAXLIFE THERAPEUTIC SOLUTIONS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2016
Last Update Date: 04/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204B PITCARIN WAY SUITE #1
AUGUSTA GA
30909-5766
US

IV. Provider business mailing address

3915 CASCADE RD SW STE 355
ATLANTA GA
30331-8520
US

V. Phone/Fax

Practice location:
  • Phone: 912-319-7250
  • Fax:
Mailing address:
  • Phone: 404-867-3093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: CAROLYN WALLER
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 404-867-3093