Provider Demographics
NPI:1194374884
Name:ELIXIR LIFESTYLE MEDICINE
Entity type:Organization
Organization Name:ELIXIR LIFESTYLE MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:STACE
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON-HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:DACM, LAC , CFMP
Authorized Official - Phone:805-644-1064
Mailing Address - Street 1:1732 PALMA DR STE 104
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-5796
Mailing Address - Country:US
Mailing Address - Phone:805-644-1064
Mailing Address - Fax:805-642-6524
Practice Address - Street 1:1732 PALMA DR STE 104
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-5796
Practice Address - Country:US
Practice Address - Phone:805-644-1064
Practice Address - Fax:805-642-6524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty