Healthcare Provider Details

I. General information

NPI: 1013189596
Provider Name (Legal Business Name): LIFESTYLES THERAPY & WELLNESS CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2008
Last Update Date: 05/17/2023
Certification Date: 05/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

276 EASTLAND DR N
TWIN FALLS ID
83301-4458
US

IV. Provider business mailing address

276 EASTLAND DR N
TWIN FALLS ID
83301-4458
US

V. Phone/Fax

Practice location:
  • Phone: 208-735-8563
  • Fax: 208-735-8564
Mailing address:
  • Phone: 208-735-8563
  • Fax: 208-735-8564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-1352
License Number StateID

VIII. Authorized Official

Name: M. ANDREW MIX
Title or Position: PRESIDENT
Credential: RPT
Phone: 208-735-8563