Healthcare Provider Details

I. General information

NPI: 1265230601
Provider Name (Legal Business Name): PRIMELIFE HEALTH AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2025
Last Update Date: 03/03/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 THACKERAY TRL STE 103
OCONOMOWOC WI
53066-4342
US

IV. Provider business mailing address

925 GENESEE ST # 180620
DELAFIELD WI
53018-9998
US

V. Phone/Fax

Practice location:
  • Phone: 866-329-4264
  • Fax:
Mailing address:
  • Phone: 262-330-0062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ERIC M ELLIOT
Title or Position: VICE PRESIDENT
Credential: DMSC, PA-C
Phone: 262-330-0062