Provider Demographics
NPI:1437331618
Name:INSTITUTE FOR DYNAMIC LIVING INC
Entity Type:Organization
Organization Name:INSTITUTE FOR DYNAMIC LIVING INC
Other - Org Name:BETTER LIFE WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:STOLLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:765-935-0070
Mailing Address - Street 1:1528 NW 5TH ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1844
Mailing Address - Country:US
Mailing Address - Phone:765-935-0070
Mailing Address - Fax:765-935-0073
Practice Address - Street 1:1528 NW 5TH ST
Practice Address - Street 2:SUITE 100
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1844
Practice Address - Country:US
Practice Address - Phone:765-935-0070
Practice Address - Fax:765-935-0073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10024995A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201293710AMedicaid
IN235370Medicare PIN