Healthcare Provider Details

I. General information

NPI: 1255815981
Provider Name (Legal Business Name): WELLNESS LIFE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2018
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1842 US HIGHWAY 84 W
CAIRO GA
39827-4224
US

IV. Provider business mailing address

1842 US HIGHWAY 84 W
CAIRO GA
39827-4224
US

V. Phone/Fax

Practice location:
  • Phone: 229-377-2002
  • Fax: 229-377-0930
Mailing address:
  • Phone: 229-397-5433
  • Fax: 229-377-0930

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. LAURA M ODUM
Title or Position: PRACTICE MANAGER
Credential: CPC
Phone: 229-397-5433