Provider Demographics
NPI:1184309288
Name:LIFE THRIVE WELLNESS LLC
Entity type:Organization
Organization Name:LIFE THRIVE WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DESIREE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORES
Authorized Official - Suffix:
Authorized Official - Credentials:MOTR/L
Authorized Official - Phone:208-741-0395
Mailing Address - Street 1:1729 E BOISE AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-5403
Mailing Address - Country:US
Mailing Address - Phone:208-741-0395
Mailing Address - Fax:
Practice Address - Street 1:270 S ORCHARD ST STE B
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-1234
Practice Address - Country:US
Practice Address - Phone:208-741-0395
Practice Address - Fax:208-473-7340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-16
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Single Specialty