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General NPI Number Information
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NPI Number | 1578240008
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Entity Type | Organization
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Legal Business Name | LIFE MOBILE WELLNESS, LLC
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Dates
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Enumeration Date | 06/27/2023
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Last Update Date | 08/27/2024
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Provider Practice Location Address
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Address Line | 4324 STONE MOUNTAIN DRIVE
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City | GASTONIA
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State | NC
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Zip | 28054
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Country | US
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Telephone | 984-279-0776
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Fax |
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Provider Business Mailing Address
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Address Line | 1235 EAST BLVD STE E
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City | CHARLOTTE
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State | NC
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Zip | 28203-5876
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Country | US
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Telephone | 980-246-1342
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | LAVARE SELTUN
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Credential | FNP-C
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Telephone | 980-745-2195
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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