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General NPI Number Information
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NPI Number | 1982415873
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Entity Type | Organization
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Legal Business Name | CULTIVATING LIFE CLINIC
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Dates
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Enumeration Date | 01/18/2025
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Last Update Date | 01/18/2025
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Provider Practice Location Address
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Address Line | 3607 S MAIN ST
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City | SOUTH BEND
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State | IN
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Zip | 46614-1723
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Country | US
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Telephone | 574-444-0256
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Fax |
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Provider Business Mailing Address
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Address Line | 3607 S MAIN ST STE 1
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City | SOUTH BEND
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State | IN
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Zip | 46614-1723
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Country | US
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Telephone | 574-444-0256
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | LARISSA CHISM BUGGS
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Credential | MD
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Telephone | 574-444-0256
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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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 | 261QC1500X
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Taxonomy Name | Community Health Clinic/Center
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License Number |
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License Number State |
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