Provider Demographics
NPI:1386524437
Name:PHYSICAL LIFE LLC
Entity type:Organization
Organization Name:PHYSICAL LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TREVINO
Authorized Official - Middle Name:
Authorized Official - Last Name:SIMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, FNP
Authorized Official - Phone:770-380-9756
Mailing Address - Street 1:191 BARCLAY DR
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-8035
Mailing Address - Country:US
Mailing Address - Phone:678-272-0464
Mailing Address - Fax:678-272-0862
Practice Address - Street 1:850 HAMPTON RD
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-6514
Practice Address - Country:US
Practice Address - Phone:678-272-0464
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-09-08
Last Update Date:2025-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty