=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033938394
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALIVE TOTAL WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2024
-----------------------------------------------------
Last Update Date | 06/23/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4020 EDINBURGH CT
-----------------------------------------------------
City | SUFFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23434-7055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-535-5332
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4020 EDINBURGH CT
-----------------------------------------------------
City | SUFFOLK
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23434-7055
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-535-5332
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. NEIL WILLIAMS
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 757-535-5332
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------