Provider Demographics
NPI:1801597257
Name:WELLLIFE, LLC
Entity type:Organization
Organization Name:WELLLIFE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:GERMAINE
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:719-694-8782
Mailing Address - Street 1:975 GARDEN OF THE GODS RD STE E
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-3434
Mailing Address - Country:US
Mailing Address - Phone:719-694-8782
Mailing Address - Fax:719-694-9375
Practice Address - Street 1:975 GARDEN OF THE GODS RD STE E
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-3434
Practice Address - Country:US
Practice Address - Phone:719-694-8782
Practice Address - Fax:719-694-9375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty