=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114239845
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW IMAGE LIFE COACHES & ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2010
-----------------------------------------------------
Last Update Date | 07/10/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4334 SNOW MASS LANE
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-362-6256
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4334 SNOW MASS LANE
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-362-6256
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLIENT COACH/OWNER
-----------------------------------------------------
Name | REGINALD A WHITE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 901-362-6256
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174H00000X
-----------------------------------------------------
Taxonomy Name | Health Educator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------