Provider Demographics
NPI:1316539687
Name:FREE LIFE WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:FREE LIFE WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:STARR
Authorized Official - Last Name:GOOCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-687-1773
Mailing Address - Street 1:1731 W BASELINE RD STE 113
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-5782
Mailing Address - Country:US
Mailing Address - Phone:480-687-1773
Mailing Address - Fax:480-687-2986
Practice Address - Street 1:1731 W BASELINE RD STE 113
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-5782
Practice Address - Country:US
Practice Address - Phone:480-687-1773
Practice Address - Fax:480-687-2986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-09
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ100618Medicaid