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General NPI Number Information
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NPI Number | 1184309288
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Entity Type | Organization
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Legal Business Name | LIFE THRIVE WELLNESS LLC
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Dates
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Enumeration Date | 06/16/2023
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Last Update Date | 06/16/2023
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Provider Practice Location Address
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Address Line | 270 S ORCHARD ST STE B
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City | BOISE
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State | ID
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Zip | 83705-1234
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Country | US
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Telephone | 208-741-0395
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Fax | 208-473-7340
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Provider Business Mailing Address
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Address Line | 1729 E BOISE AVE
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City | BOISE
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State | ID
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Zip | 83706-5403
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Country | US
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Telephone | 208-741-0395
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DESIREE MOORES
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Credential | MOTR/L
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Telephone | 208-741-0395
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number |
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License Number State |
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