Provider Demographics
NPI:1467816199
Name:TOTAL LIFE CLINIC PLLC
Entity Type:Organization
Organization Name:TOTAL LIFE CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHELBYANN
Authorized Official - Middle Name:BERNICE
Authorized Official - Last Name:ALDRIDGE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-878-6413
Mailing Address - Street 1:2311 PARK AVE
Mailing Address - Street 2:UNIT 2 SUITE 6&8
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-2104
Mailing Address - Country:US
Mailing Address - Phone:208-878-6413
Mailing Address - Fax:208-878-6417
Practice Address - Street 1:2311 PARK AVE
Practice Address - Street 2:UNIT 2 SUITE 6&8
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2104
Practice Address - Country:US
Practice Address - Phone:208-878-6413
Practice Address - Fax:208-878-6417
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-08
Last Update Date:2023-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1467816199Medicaid
ID1609107176Medicaid