Healthcare Provider Details

I. General information

NPI: 1548419237
Provider Name (Legal Business Name): TOTALLY FIT 4 LIFE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2008
Last Update Date: 09/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7476 WATERSIDE LOOP RD SUITE 600
DENVER NC
28037-7679
US

IV. Provider business mailing address

7476 WATERSIDE LOOP RD SUITE 600
DENVER NC
28037-7679
US

V. Phone/Fax

Practice location:
  • Phone: 704-822-5433
  • Fax:
Mailing address:
  • Phone: 704-822-5433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084B0002X
TaxonomyObesity Medicine (Psychiatry & Neurology) Physician
License Number128967
License Number StateNC

VIII. Authorized Official

Name: MS. DEBRA DIANE POWELL
Title or Position: PRESIDENT
Credential: PA
Phone: 704-822-5433