Provider Demographics
NPI:1568949097
Name:LIFESPAN WELLNESS LLC
Entity Type:Organization
Organization Name:LIFESPAN WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RENATA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLLIMAN
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:251-422-1979
Mailing Address - Street 1:101 ROUSELLE PL STE A
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39564-3074
Mailing Address - Country:US
Mailing Address - Phone:228-327-8210
Mailing Address - Fax:
Practice Address - Street 1:101 ROUSELLE PL STE A
Practice Address - Street 2:
Practice Address - City:OCEAN SPRINGS
Practice Address - State:MS
Practice Address - Zip Code:39564-3074
Practice Address - Country:US
Practice Address - Phone:228-327-8210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-27
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1127426261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service