Provider Demographics
NPI:1265829626
Name:EXECUTIVE LEVEL WELLNESS
Entity Type:Organization
Organization Name:EXECUTIVE LEVEL WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:HUGHES
Authorized Official - Suffix:
Authorized Official - Credentials:GNP-BC
Authorized Official - Phone:731-571-8808
Mailing Address - Street 1:1167 JR JONES RD
Mailing Address - Street 2:
Mailing Address - City:HUMBOLDT
Mailing Address - State:TN
Mailing Address - Zip Code:38343-8080
Mailing Address - Country:US
Mailing Address - Phone:731-571-8808
Mailing Address - Fax:888-318-1702
Practice Address - Street 1:111 STONEBRIDGE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2040
Practice Address - Country:US
Practice Address - Phone:731-420-3334
Practice Address - Fax:888-318-1702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-22
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN013215314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility