1124252598 NPI number — BREATH OF LIFE CHIROPRACTIC WELLNESS CENTER P.C.

Table of content: (NPI 1124252598)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124252598 NPI number — BREATH OF LIFE CHIROPRACTIC WELLNESS CENTER P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BREATH OF LIFE CHIROPRACTIC WELLNESS CENTER P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124252598
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
322 BAY ST
Provider Second Line Business Mailing Address:
#3
Provider Business Mailing Address City Name:
PETOSKEY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49770-2489
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-622-8828
Provider Business Mailing Address Fax Number:
231-622-8829

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
322 BAY ST
Provider Second Line Business Practice Location Address:
#3
Provider Business Practice Location Address City Name:
PETOSKEY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49770-2489
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-622-8828
Provider Business Practice Location Address Fax Number:
231-622-8829
Provider Enumeration Date:
05/13/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DENHOLM
Authorized Official First Name:
KYLE
Authorized Official Middle Name:
MARTIN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
989-619-4709

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2301009264 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5195192 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 950B01090 . This is a "BCBS OF MICHIGAN" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".