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General NPI Number Information
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NPI Number | 1508391756
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Entity Type | Organization
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Legal Business Name | MISTER LIFE COACH
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Dates
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Enumeration Date | 04/25/2017
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Last Update Date | 04/25/2017
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Provider Practice Location Address
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Address Line | 3681 N DECATUR RD APT R11
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City | DECATUR
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State | GA
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Zip | 30032-1062
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Country | US
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Telephone | 631-553-7131
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 283
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City | REX
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State | GA
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Zip | 30273-0283
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Country | US
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Telephone | 631-553-7131
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Fax |
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Authorized Official
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Title or Position | LIFE COACH
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Name | ROBERT GREEN
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Credential |
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Telephone | 631-553-7131
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number |
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License Number State | GA
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