Provider Demographics
NPI:1508481862
Name:LIFEGATE HEALTH & WELLNESS
Entity Type:Organization
Organization Name:LIFEGATE HEALTH & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EMMANUELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHASSAGNE
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:954-770-7059
Mailing Address - Street 1:3784 HARRIS BLVD NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-6098
Mailing Address - Country:US
Mailing Address - Phone:954-770-7059
Mailing Address - Fax:
Practice Address - Street 1:3784 HARRIS BLVD NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-6098
Practice Address - Country:US
Practice Address - Phone:954-770-7059
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LIFEGATE HEALTH & WELLNESS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-06-12
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No251E00000XAgenciesHome Health
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No302R00000XManaged Care OrganizationsHealth Maintenance Organization