Provider Demographics
NPI:1043079742
Name:ENRICHED LIFE MEDICAL
Entity type:Organization
Organization Name:ENRICHED LIFE MEDICAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:M
Authorized Official - Last Name:RICH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:903-309-9373
Mailing Address - Street 1:2412 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GUN BARREL CITY
Mailing Address - State:TX
Mailing Address - Zip Code:75156-3638
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2412 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GUN BARREL CITY
Practice Address - State:TX
Practice Address - Zip Code:75156-3638
Practice Address - Country:US
Practice Address - Phone:903-309-9373
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-15
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty