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General NPI Number Information
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NPI Number | 1568949097
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Entity Type | Organization
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Legal Business Name | LIFESPAN WELLNESS LLC
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Dates
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Enumeration Date | 07/27/2018
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Last Update Date | 07/27/2018
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Provider Practice Location Address
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Address Line | 101 ROUSELLE PL STE A
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City | OCEAN SPRINGS
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State | MS
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Zip | 39564-3074
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Country | US
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Telephone | 228-327-8210
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Fax |
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Provider Business Mailing Address
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Address Line | 101 ROUSELLE PL STE A
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City | OCEAN SPRINGS
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State | MS
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Zip | 39564-3074
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Country | US
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Telephone | 228-327-8210
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | RENATA HOLLIMAN
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Credential | FNP-C
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Telephone | 251-422-1979
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | 1127426
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License Number State | MS
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