Provider Demographics
NPI:1043930993
Name:WHOLLY AUTHENTIC LIFE LLC
Entity Type:Organization
Organization Name:WHOLLY AUTHENTIC LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MBR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TAMMIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:LCPC
Authorized Official - Phone:406-799-2711
Mailing Address - Street 1:PO BOX 907
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:MT
Mailing Address - Zip Code:59436-0907
Mailing Address - Country:US
Mailing Address - Phone:406-799-2711
Mailing Address - Fax:406-467-3407
Practice Address - Street 1:201 1ST AVE N
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:MT
Practice Address - Zip Code:59436-9245
Practice Address - Country:US
Practice Address - Phone:406-799-2711
Practice Address - Fax:406-467-3407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-31
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center