Provider Demographics
NPI:1598531923
Name:THE CELESTIAL LIFE LLC
Entity Type:Organization
Organization Name:THE CELESTIAL LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:THEUS
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:203-680-0583
Mailing Address - Street 1:272 SUNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-3885
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:272 SUNWOOD DR
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-3885
Practice Address - Country:US
Practice Address - Phone:203-680-0583
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service