Provider Demographics
NPI:1275043671
Name:FRUITFUL LIVING NOW LLC
Entity Type:Organization
Organization Name:FRUITFUL LIVING NOW LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:TILLIK
Authorized Official - Middle Name:RAFEL
Authorized Official - Last Name:DEWELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:704-712-4958
Mailing Address - Street 1:610 E 7TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-2923
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:331 E MAIN ST
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730-5383
Practice Address - Country:US
Practice Address - Phone:704-712-4958
Practice Address - Fax:704-712-4958
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-11
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty