# WHOLELIFE AUTHENTIC CARE PROVIDER NETWORK

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1386200889
- **Authorized official:** NICOLE HAVRILLA (BOARD PRESIDENT)
- **Authorized official phone:** (806) 220-6455

## Contact information

- **Practice address:** 1000 BONNIE BRAE AVE STE 120, FORT WORTH, TX 76111-4301
- **Practice address phone:** (817) 706-3128
- **Mailing address:** PO BOX 11043, FORT WORTH, TX 76110-0043
- **Mailing address phone:** (817) 706-3128

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 208000000X | Pediatrics Physician | — | NULL | — |
| 208000000X | Pediatrics Physician | — | — | — |
| 208D00000X | General Practice Physician | — | NULL | Yes |
| 208D00000X | General Practice Physician | — | — | Yes |

## Other

- **Enumeration date:** 05/10/2019
- **Last updated:** 06/10/2022