Provider Demographics
NPI:1578240008
Name:LIFE MOBILE WELLNESS, LLC
Entity Type:Organization
Organization Name:LIFE MOBILE WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAVARE
Authorized Official - Middle Name:
Authorized Official - Last Name:SELTUN
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:980-246-1342
Mailing Address - Street 1:219 W MAIN AVE UNIT 8
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-4140
Mailing Address - Country:US
Mailing Address - Phone:980-246-1342
Mailing Address - Fax:
Practice Address - Street 1:219 W MAIN AVE UNIT 8
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-4140
Practice Address - Country:US
Practice Address - Phone:980-246-1342
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-27
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty