MEDICARE: TREE OF LIFE HEATHCARE, INC.

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	RN085223	GA

General Provider Information

NPI Number	:	1811326655
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TREE OF LIFE HEATHCARE, INC.

Provider Business Mailing Address
First Line	:	PO BOX 9205
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31908-9205
Country	:	US
Telephone Number	:	706-225-0355
Fax Number	:	706-225-0360

Provider Business Practice Location Address
First Line	:	1968 NORTH AVE
Second Line	:
City	:	COLUMBUS
State	:	GA
Zip	:	31901-1525
Country	:	US
Telephone Number	:	706-225-0355
Fax Number	:	706-225-0360

Authorized Official
Title or Position	:	PRESIDENT / CEO
Name	:	MR. LOWELL CLIATT
Credential	:
Telephone Number	:	706-225-0355

Provider Enumeration Date	:	11/02/2013
Last Update Date	:	11/02/2013

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