Provider Demographics
NPI:1467028530
Name:CIRCLE OF LIFE HOLISTIC CARE, LLC
Entity Type:Organization
Organization Name:CIRCLE OF LIFE HOLISTIC CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LYLES
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:253-224-0509
Mailing Address - Street 1:708 BROADWAY STE 105
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-3750
Mailing Address - Country:US
Mailing Address - Phone:253-224-0509
Mailing Address - Fax:
Practice Address - Street 1:708 BROADWAY STE 105
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-3750
Practice Address - Country:US
Practice Address - Phone:253-224-0509
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-31
Last Update Date:2021-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)