Healthcare Provider Details

I. General information

NPI: 1790811784
Provider Name (Legal Business Name): LIFESTYLE WELLNESS CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 MAIN STREET
PINEVILLE MO
64856
US

IV. Provider business mailing address

PO BOX 37
PINEVILLE MO
64856-0037
US

V. Phone/Fax

Practice location:
  • Phone: 417-223-4103
  • Fax:
Mailing address:
  • Phone: 417-223-4103
  • Fax: 417-223-4102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number003822
License Number StateMO

VIII. Authorized Official

Name: LESLI G SMITH
Title or Position: MANAGING MEMBER
Credential:
Phone: 417-223-4103