Provider Demographics
NPI:1770178162
Name:HEAL THYSELF LLC
Entity type:Organization
Organization Name:HEAL THYSELF LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MS.
Authorized Official - Prefix:
Authorized Official - First Name:SHERRELL
Authorized Official - Middle Name:
Authorized Official - Last Name:ECHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-539-3710
Mailing Address - Street 1:RESIDENSE ADDRESS : 147 WILLOW COVE ROAD
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3698 INNER PERIMETER RD STE 3603
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1047
Practice Address - Country:US
Practice Address - Phone:229-539-3710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11-790-2611Medicaid