Healthcare Provider Details

I. General information

NPI: 1396259420
Provider Name (Legal Business Name): WHOLE LIFE SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2017
Last Update Date: 11/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 ASH ST STE 150
SPOONER WI
54801-1201
US

IV. Provider business mailing address

PO BOX 93
SPOONER WI
54801-0093
US

V. Phone/Fax

Practice location:
  • Phone: 715-645-0336
  • Fax:
Mailing address:
  • Phone: 715-645-0336
  • Fax: 715-645-0336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1819-132
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number11506-135
License Number StateWI

VIII. Authorized Official

Name: GARY P EHRICH
Title or Position: DIRECTOR
Credential: ICS, CSAC
Phone: 715-645-0336