Provider Demographics
NPI:1184379091
Name:SACRED LIFE WELLNESS LLC
Entity type:Organization
Organization Name:SACRED LIFE WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDUARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:808-209-2263
Mailing Address - Street 1:PO BOX 1023
Mailing Address - Street 2:
Mailing Address - City:KAPAAU
Mailing Address - State:HI
Mailing Address - Zip Code:96755-1023
Mailing Address - Country:US
Mailing Address - Phone:808-209-2263
Mailing Address - Fax:833-402-1821
Practice Address - Street 1:53-4411 AKONI PULE HWY
Practice Address - Street 2:
Practice Address - City:KAPAAU
Practice Address - State:HI
Practice Address - Zip Code:96755
Practice Address - Country:US
Practice Address - Phone:808-209-2263
Practice Address - Fax:833-402-1821
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-18
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty