Provider Demographics
NPI:1841698123
Name:EXECUTIVE LEVEL WELLNESS
Entity type:Organization
Organization Name:EXECUTIVE LEVEL WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:HUGHES
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:731-571-8808
Mailing Address - Street 1:1167 JR JONES RD
Mailing Address - Street 2:
Mailing Address - City:HUMBOLDT
Mailing Address - State:TN
Mailing Address - Zip Code:38343
Mailing Address - Country:US
Mailing Address - Phone:731-431-2818
Mailing Address - Fax:888-318-1702
Practice Address - Street 1:1167 JR JONES RD
Practice Address - Street 2:
Practice Address - City:HUMBOLDT
Practice Address - State:TN
Practice Address - Zip Code:38343-8080
Practice Address - Country:US
Practice Address - Phone:731-431-2818
Practice Address - Fax:888-318-1702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-18
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN013215364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontologyGroup - Single Specialty