Provider Demographics
NPI:1619540077
Name:LIFE FULFILLMENT AND WELLNESS LLC
Entity Type:Organization
Organization Name:LIFE FULFILLMENT AND WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:IMELDA
Authorized Official - Middle Name:RAMIREZ
Authorized Official - Last Name:REVERON
Authorized Official - Suffix:
Authorized Official - Credentials:MHC
Authorized Official - Phone:210-600-4117
Mailing Address - Street 1:21916 PARK VIEW DR
Mailing Address - Street 2:
Mailing Address - City:GARDEN RIDGE
Mailing Address - State:TX
Mailing Address - Zip Code:78266-2749
Mailing Address - Country:US
Mailing Address - Phone:210-844-9985
Mailing Address - Fax:210-600-3849
Practice Address - Street 1:4335 W PIEDRAS DR STE 103
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78228-1215
Practice Address - Country:US
Practice Address - Phone:210-600-4117
Practice Address - Fax:210-600-3849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-22
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1144893694Medicaid