Provider Demographics
NPI:1255901104
Name:LIFE HEALTH & WELLNESS CENTER, LLC
Entity type:Organization
Organization Name:LIFE HEALTH & WELLNESS CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NATALIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCALL-GASTON
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-BC
Authorized Official - Phone:678-641-4391
Mailing Address - Street 1:1707 NORTH BLAIRS BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30168
Mailing Address - Country:US
Mailing Address - Phone:470-513-3908
Mailing Address - Fax:770-502-6492
Practice Address - Street 1:1707 NORTH BLAIRS BRIDGE RD
Practice Address - Street 2:
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30168
Practice Address - Country:US
Practice Address - Phone:470-513-3908
Practice Address - Fax:770-502-6492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-07-01
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003137957DMedicaid