Provider Demographics
NPI:1437530185
Name:MAN ALIVE, LLC
Entity Type:Organization
Organization Name:MAN ALIVE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BARRUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-984-5806
Mailing Address - Street 1:9430 NE VANCOUVER MALL DR
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-6172
Mailing Address - Country:US
Mailing Address - Phone:360-984-5806
Mailing Address - Fax:360-984-5994
Practice Address - Street 1:9430 NE VANCOUVER MALL DR
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-6172
Practice Address - Country:US
Practice Address - Phone:360-253-6947
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-17
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00043839207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty