Provider Demographics
NPI:1386200889
Name:WHOLELIFE AUTHENTIC CARE PROVIDER NETWORK
Entity type:Organization
Organization Name:WHOLELIFE AUTHENTIC CARE PROVIDER NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOARD PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:HAVRILLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:806-220-6455
Mailing Address - Street 1:PO BOX 11043
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-0043
Mailing Address - Country:US
Mailing Address - Phone:817-706-3128
Mailing Address - Fax:
Practice Address - Street 1:1000 BONNIE BRAE AVE STE 120
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76111-4301
Practice Address - Country:US
Practice Address - Phone:817-706-3128
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty