Provider Demographics
NPI:1982415873
Name:CULTIVATING LIFE CLINIC
Entity type:Organization
Organization Name:CULTIVATING LIFE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LARISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHISM BUGGS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:574-444-0256
Mailing Address - Street 1:3607 S MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-1723
Mailing Address - Country:US
Mailing Address - Phone:574-444-0256
Mailing Address - Fax:
Practice Address - Street 1:3607 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-1723
Practice Address - Country:US
Practice Address - Phone:574-444-0256
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-18
Last Update Date:2025-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty