Provider Demographics
NPI:1902000433
Name:LIFE QUEST WELLNESS CENTER
Entity Type:Organization
Organization Name:LIFE QUEST WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDRE
Authorized Official - Middle Name:J
Authorized Official - Last Name:CAMELLI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:330-609-0355
Mailing Address - Street 1:1980 NILES CORTLAND RD NE
Mailing Address - Street 2:
Mailing Address - City:CORTLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44410-9405
Mailing Address - Country:US
Mailing Address - Phone:330-609-0355
Mailing Address - Fax:330-609-0335
Practice Address - Street 1:1980 NILES CORTLAND RD NE
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:OH
Practice Address - Zip Code:44410-9405
Practice Address - Country:US
Practice Address - Phone:330-609-0355
Practice Address - Fax:330-609-0335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2008-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3112111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9361181Medicare PIN