Provider Demographics
NPI:1033457239
Name:LIFE WELLNESS CENTER & BOOKSTORE, L.L.C.
Entity Type:Organization
Organization Name:LIFE WELLNESS CENTER & BOOKSTORE, L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:LIBERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-745-0200
Mailing Address - Street 1:15 EARNEST DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:BLAIRSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30512-8627
Mailing Address - Country:US
Mailing Address - Phone:706-745-0200
Mailing Address - Fax:
Practice Address - Street 1:15 EARNEST DR
Practice Address - Street 2:SUITE A
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-8627
Practice Address - Country:US
Practice Address - Phone:706-745-0200
Practice Address - Fax:706-745-0889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-22
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA059457207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty