Provider Demographics
NPI:1710003801
Name:HEALTH CONCEPTS FOR LIFE LLC
Entity Type:Organization
Organization Name:HEALTH CONCEPTS FOR LIFE LLC
Other - Org Name:MARY WALL TUCKER
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY WALL
Authorized Official - Middle Name:
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:828-696-9888
Mailing Address - Street 1:580 UPWARD RD
Mailing Address - Street 2:UNIT 1
Mailing Address - City:FLAT ROCK
Mailing Address - State:NC
Mailing Address - Zip Code:28731-9477
Mailing Address - Country:US
Mailing Address - Phone:828-696-9888
Mailing Address - Fax:828-696-1947
Practice Address - Street 1:580 UPWARD RD
Practice Address - Street 2:UNIT 1
Practice Address - City:FLAT ROCK
Practice Address - State:NC
Practice Address - Zip Code:28731-8592
Practice Address - Country:US
Practice Address - Phone:828-696-9888
Practice Address - Fax:828-696-1947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2009-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC72955261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCF50320Medicare UPIN
NCS91995Medicare UPIN