=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265230601
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRIMELIFE HEALTH AND WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2025
-----------------------------------------------------
Last Update Date | 03/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 888 THACKERAY TRL STE 103
-----------------------------------------------------
City | OCONOMOWOC
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53066-4342
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-329-4264
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 925 GENESEE ST # 180620
-----------------------------------------------------
City | DELAFIELD
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53018-9998
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-330-0062
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | DR. ERIC M ELLIOT
-----------------------------------------------------
Credential | DMSC, PA-C
-----------------------------------------------------
Telephone | 262-330-0062
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2083B0002X
-----------------------------------------------------
Taxonomy Name | Obesity Medicine (Preventive Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 202D00000X
-----------------------------------------------------
Taxonomy Name | Integrative Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------