Provider Demographics
NPI:1649815796
Name:180 HEALTH LIFESTYLE WELLNESS CENTERS
Entity type:Organization
Organization Name:180 HEALTH LIFESTYLE WELLNESS CENTERS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TARA
Authorized Official - Middle Name:
Authorized Official - Last Name:MEEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-887-0340
Mailing Address - Street 1:1936 S GLENSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65804-2305
Mailing Address - Country:US
Mailing Address - Phone:417-827-0450
Mailing Address - Fax:
Practice Address - Street 1:1936 S GLENSTONE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2305
Practice Address - Country:US
Practice Address - Phone:417-827-0450
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-13
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty