MEDICARE: WHOLLY AUTHENTIC LIFE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1043930993
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WHOLLY AUTHENTIC LIFE LLC

Provider Business Mailing Address
First Line	:	PO BOX 907
Second Line	:
City	:	FAIRFIELD
State	:	MT
Zip	:	59436-0907
Country	:	US
Telephone Number	:	406-799-2711
Fax Number	:	406-467-3407

Provider Business Practice Location Address
First Line	:	201 1ST AVE N
Second Line	:
City	:	FAIRFIELD
State	:	MT
Zip	:	59436-9245
Country	:	US
Telephone Number	:	406-799-2711
Fax Number	:	406-467-3407

Authorized Official
Title or Position	:	MBR
Name	:	MRS. TAMMIE S SMITH
Credential	:	LCPC
Telephone Number	:	406-799-2711

Provider Enumeration Date	:	08/31/2022
Last Update Date	:	09/29/2023

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Directions to “WHOLLY AUTHENTIC LIFE LLC ” Practice Location

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