Provider Demographics
NPI:1568850337
Name:EAT WELL FOR LIFE, LLC
Entity Type:Organization
Organization Name:EAT WELL FOR LIFE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCAS
Authorized Official - Suffix:
Authorized Official - Credentials:RD, LDN
Authorized Official - Phone:717-372-6687
Mailing Address - Street 1:138 ROLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMBERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17201-1444
Mailing Address - Country:US
Mailing Address - Phone:717-372-6687
Mailing Address - Fax:717-446-0033
Practice Address - Street 1:35 RAGGED EDGE RD
Practice Address - Street 2:
Practice Address - City:CHAMBERSBURG
Practice Address - State:PA
Practice Address - Zip Code:17202-4450
Practice Address - Country:US
Practice Address - Phone:717-372-6687
Practice Address - Fax:717-446-0033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-02
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QE0700XAmbulatory Health Care FacilitiesClinic/CenterEnd-Stage Renal Disease (ESRD) Treatment
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAT1434218103OtherCERTIFICATE OF ORGANIZATION