Provider Demographics
NPI:1962675702
Name:LIFE WELLNESS CENTER INC
Entity Type:Organization
Organization Name:LIFE WELLNESS CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GERARDO
Authorized Official - Middle Name:FRANCISCO
Authorized Official - Last Name:RODRIGUEZ-MENENDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:305-525-3629
Mailing Address - Street 1:3119 CORAL WAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CORAL GABLES
Mailing Address - State:FL
Mailing Address - Zip Code:33145-3209
Mailing Address - Country:US
Mailing Address - Phone:305-525-3629
Mailing Address - Fax:305-969-1521
Practice Address - Street 1:3119 CORAL WAY
Practice Address - Street 2:SUITE 200
Practice Address - City:CORAL GABLES
Practice Address - State:FL
Practice Address - Zip Code:33145-3209
Practice Address - Country:US
Practice Address - Phone:305-525-3629
Practice Address - Fax:305-969-1521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-11
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY5490302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization