Provider Demographics
NPI:1437433190
Name:TREE OF LIFE HEALTH ALLIANCE LLC
Entity Type:Organization
Organization Name:TREE OF LIFE HEALTH ALLIANCE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:D
Authorized Official - Last Name:DELIMA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-267-2790
Mailing Address - Street 1:PO BOX 925
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-0925
Mailing Address - Country:US
Mailing Address - Phone:770-267-2790
Mailing Address - Fax:770-207-0652
Practice Address - Street 1:333 ALCOVY ST STE 10
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655-2180
Practice Address - Country:US
Practice Address - Phone:770-267-2790
Practice Address - Fax:770-207-0652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-29
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA028528261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care