Healthcare Provider Details

I. General information

NPI: 1093377855
Provider Name (Legal Business Name): LIFES ENERGY WELLNESS CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2019
Last Update Date: 07/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2324 WEST ZION ROAD SUITE #112
SALISBURY MD
21804
US

IV. Provider business mailing address

PO BOX 123
EASTON MD
21601-8901
US

V. Phone/Fax

Practice location:
  • Phone: 800-867-2395
  • Fax: 410-443-0842
Mailing address:
  • Phone: 800-867-2395
  • Fax: 410-443-0842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: ANDREA KELLEY-FREEMAN
Title or Position: CEO
Credential: MS, LCADC, LCPC
Phone: 800-867-2395