Provider Demographics
NPI:1306273347
Name:ILIVEWELL NUTRITION THERPAY, LLC
Entity type:Organization
Organization Name:ILIVEWELL NUTRITION THERPAY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ADRIEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PACZOSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-547-9274
Mailing Address - Street 1:801 RANCH ROAD 620 S
Mailing Address - Street 2:
Mailing Address - City:LAKEWAY
Mailing Address - State:TX
Mailing Address - Zip Code:78734-5316
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:801 RANCH ROAD 620 S
Practice Address - Street 2:
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-5316
Practice Address - Country:US
Practice Address - Phone:512-547-9274
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRACTICE FUSION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-10-05
Last Update Date:2013-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT82817261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center