Healthcare Provider Details

I. General information

NPI: 1871088674
Provider Name (Legal Business Name): LIFEWISE ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2018
Last Update Date: 05/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 HIGHWAY 2 W STE 10
DEVILS LAKE ND
58301-2913
US

IV. Provider business mailing address

210 HIGHWAY 2 W STE 10
DEVILS LAKE ND
58301-2913
US

V. Phone/Fax

Practice location:
  • Phone: 701-662-1046
  • Fax: 866-528-9548
Mailing address:
  • Phone: 701-662-1046
  • Fax: 866-528-9548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DARRIN COX
Title or Position: CO OWNER
Credential: LICSW
Phone: 701-662-1046