=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295158699
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFE ENRICHMENT AND WELLNESS SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2014
-----------------------------------------------------
Last Update Date | 01/22/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 608 STONECREST DRIVE
-----------------------------------------------------
City | LOGANVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-949-3184
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 608 STONECREST DRIVE
-----------------------------------------------------
City | LOGANVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-949-3184
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. CARLOS PORTER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 678-949-3184
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | GA006581
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------