Provider Demographics
NPI:1093047623
Name:LIFESTYLE WELLNESS, LLC
Entity Type:Organization
Organization Name:LIFESTYLE WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:ACOSTA
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, LD/N
Authorized Official - Phone:352-375-1158
Mailing Address - Street 1:3606 NW 24TH BLVD
Mailing Address - Street 2:#306
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32605
Mailing Address - Country:US
Mailing Address - Phone:352-375-1158
Mailing Address - Fax:
Practice Address - Street 1:519 NW 60TH STREET
Practice Address - Street 2:SUITE E
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32607
Practice Address - Country:US
Practice Address - Phone:352-375-1158
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-08
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND5247133V00000X
FLMA53113225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty