Provider Demographics
NPI:1215195466
Name:HEALTHY HABITS WELLNESS CENTER LAB
Entity Type:Organization
Organization Name:HEALTHY HABITS WELLNESS CENTER LAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:M
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:304-752-4594
Mailing Address - Street 1:140 STOLLINGS AVE
Mailing Address - Street 2:STE 3
Mailing Address - City:LOGAN
Mailing Address - State:WV
Mailing Address - Zip Code:25601-4035
Mailing Address - Country:US
Mailing Address - Phone:304-752-4594
Mailing Address - Fax:304-752-5629
Practice Address - Street 1:140 STOLLINGS AVE
Practice Address - Street 2:STE 3
Practice Address - City:LOGAN
Practice Address - State:WV
Practice Address - Zip Code:25601-4035
Practice Address - Country:US
Practice Address - Phone:304-752-4594
Practice Address - Fax:304-752-5629
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEALTHY HABITS WELLNESS CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-23
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810005483Medicaid