Healthcare Provider Details

I. General information

NPI: 1730984113
Provider Name (Legal Business Name): PROSPERITY LIFE STYLE CO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2025
Last Update Date: 02/18/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 SANTA MONICA ST.
KINGSVILLE TX
78363-3458
US

IV. Provider business mailing address

1601 SANTA MONICA ST.
KINGSVILLE TX
78363-3458
US

V. Phone/Fax

Practice location:
  • Phone: 361-355-5686
  • Fax:
Mailing address:
  • Phone: 361-355-5686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name: MS. TANIA KRISTINE LUCAS
Title or Position: OWNER
Credential: CPT/CN
Phone: 361-355-5686