Healthcare Provider Details

I. General information

NPI: 1902208903
Provider Name (Legal Business Name): LIVE WELL MEDICAL CLINIC & SPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2014
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 W COMMERCIAL AVE
MONTEREY TN
38574-1107
US

IV. Provider business mailing address

117 W COMMERCIAL AVE
MONTEREY TN
38574-1107
US

V. Phone/Fax

Practice location:
  • Phone: 931-839-6642
  • Fax: 931-839-6643
Mailing address:
  • Phone: 931-839-6642
  • Fax: 931-839-6643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: HEATHER WILSON
Title or Position: OWNER
Credential: FNP-BC
Phone: 931-839-6642