Provider Demographics
NPI:1326069485
Name:MAXLIFE HEALTH AND WELLNESS CENTER
Entity Type:Organization
Organization Name:MAXLIFE HEALTH AND WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:G
Authorized Official - Last Name:OTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:407-977-3434
Mailing Address - Street 1:425 ALEXANDRIA BLVD
Mailing Address - Street 2:SUITE 1010
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-5548
Mailing Address - Country:US
Mailing Address - Phone:407-977-3434
Mailing Address - Fax:407-977-3433
Practice Address - Street 1:425 ALEXANDRIA BLVD
Practice Address - Street 2:SUITE 1010
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-5548
Practice Address - Country:US
Practice Address - Phone:407-977-3434
Practice Address - Fax:407-977-3433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 9026111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty