MEDICARE: ALPHA LIFE MENTAL AND WELLNESS CENTER

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	261QM0850X	Adult Mental Health Clinic/Center

General Provider Information

NPI Number	:	1376136739
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALPHA LIFE MENTAL AND WELLNESS CENTER

Provider Business Mailing Address
First Line	:	13506 SUMMERPORT VILLAGE PKWY STE 320
Second Line	:
City	:	WINDERMERE
State	:	FL
Zip	:	34786-7366
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	7208 W SAND LAKE RD
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32819-5200
Country	:	US
Telephone Number	:	407-410-8621
Fax Number	:

Authorized Official
Title or Position	:	APRN
Name	:	MRS. IJEOMA E OFOKANSI
Credential	:	DNP, APRN
Telephone Number	:	407-410-8621

Provider Enumeration Date	:	02/17/2021
Last Update Date	:	08/24/2021

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