Provider Demographics
NPI:1922796408
Name:FULFILLING LIFE PLLC
Entity Type:Organization
Organization Name:FULFILLING LIFE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DI'ARA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODS
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C, CLC
Authorized Official - Phone:314-749-8906
Mailing Address - Street 1:403 GLEN CARBON RD
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-2965
Mailing Address - Country:US
Mailing Address - Phone:314-749-8906
Mailing Address - Fax:
Practice Address - Street 1:3 CLUB CENTRE CT STE B1
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-3519
Practice Address - Country:US
Practice Address - Phone:618-699-4402
Practice Address - Fax:618-590-8199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty