Provider Demographics
NPI:1194107706
Name:LIFESTYLE WELLNESS CENTER
Entity type:Organization
Organization Name:LIFESTYLE WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:IVORY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:EDD
Authorized Official - Phone:901-794-3707
Mailing Address - Street 1:3333 E SHELBY DR
Mailing Address - Street 2:SUITE 3
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38118-7256
Mailing Address - Country:US
Mailing Address - Phone:901-794-3707
Mailing Address - Fax:901-794-3690
Practice Address - Street 1:3333 E SHELBY DR
Practice Address - Street 2:SUITE 3
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38118-7256
Practice Address - Country:US
Practice Address - Phone:901-794-3707
Practice Address - Fax:901-794-3690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-19
Last Update Date:2015-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN000793975OtherSCERETARY OF STATE CONTROL NUMBER