Healthcare Provider Details

I. General information

NPI: 1922796408
Provider Name (Legal Business Name): FULFILLING LIFE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2023
Last Update Date: 04/24/2023
Certification Date: 04/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 CLUB CENTRE CT STE B1
EDWARDSVILLE IL
62025-3519
US

IV. Provider business mailing address

403 GLEN CARBON RD
GLEN CARBON IL
62034-2965
US

V. Phone/Fax

Practice location:
  • Phone: 618-699-4402
  • Fax: 618-590-8199
Mailing address:
  • Phone: 314-749-8906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DI'ARA WOODS
Title or Position: CEO
Credential: PA-C, CLC
Phone: 314-749-8906