Provider Demographics
NPI:1972780690
Name:BREATH OF LIFE WELLNESS CENTER
Entity Type:Organization
Organization Name:BREATH OF LIFE WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCAULEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:417-883-1141
Mailing Address - Street 1:2021 S. WAVERLY
Mailing Address - Street 2:SUITE 500
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804
Mailing Address - Country:US
Mailing Address - Phone:417-883-1141
Mailing Address - Fax:417-889-6627
Practice Address - Street 1:2021 S WAVERLY AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2414
Practice Address - Country:US
Practice Address - Phone:417-883-1141
Practice Address - Fax:417-889-6627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-24
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005007366251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)