MEDICARE: FULFILLING LIFE PLLC

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	207Q00000X	Family Medicine Physician
2	174400000X	Specialist

General Provider Information

NPI Number	:	1922796408
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FULFILLING LIFE PLLC

Provider Business Mailing Address
First Line	:	403 GLEN CARBON RD
Second Line	:
City	:	GLEN CARBON
State	:	IL
Zip	:	62034-2965
Country	:	US
Telephone Number	:	314-749-8906
Fax Number	:

Provider Business Practice Location Address
First Line	:	3 CLUB CENTRE CT STE B1
Second Line	:
City	:	EDWARDSVILLE
State	:	IL
Zip	:	62025-3519
Country	:	US
Telephone Number	:	618-699-4402
Fax Number	:	618-590-8199

Authorized Official
Title or Position	:	CEO
Name	:	DI'ARA WOODS
Credential	:	PA-C, CLC
Telephone Number	:	314-749-8906

Provider Enumeration Date	:	04/24/2023
Last Update Date	:	04/24/2023

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