Provider Demographics
NPI:1043759863
Name:LIFE ENHANCING WELLNESS CENTERS, LLC
Entity Type:Organization
Organization Name:LIFE ENHANCING WELLNESS CENTERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEMETRIOS
Authorized Official - Middle Name:A
Authorized Official - Last Name:KYDONIEUS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:434-481-2012
Mailing Address - Street 1:8881 SEMINOLE TRL
Mailing Address - Street 2:
Mailing Address - City:RUCKERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22968-3448
Mailing Address - Country:US
Mailing Address - Phone:434-481-2012
Mailing Address - Fax:
Practice Address - Street 1:8881 SEMINOLE TRL
Practice Address - Street 2:
Practice Address - City:RUCKERSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22968-3448
Practice Address - Country:US
Practice Address - Phone:434-481-2012
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-13
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556817111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Single Specialty