Provider Demographics
NPI:1568913283
Name:HIGHLIFE ADDICTION MEDICINE AND COUNSELING LLC
Entity Type:Organization
Organization Name:HIGHLIFE ADDICTION MEDICINE AND COUNSELING LLC
Other - Org Name:HIGHLIFE ADDICTION MEDICINE AND COUNSELING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MM/CEO
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HAIMES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-543-4843
Mailing Address - Street 1:5925 CLEVELAND AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43231-2208
Mailing Address - Country:US
Mailing Address - Phone:740-601-6071
Mailing Address - Fax:800-275-2415
Practice Address - Street 1:5925 CLEVELAND AVE
Practice Address - Street 2:SUITE C
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43231-2208
Practice Address - Country:US
Practice Address - Phone:740-601-6071
Practice Address - Fax:800-275-2415
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HIGHLIFE HEALTH LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-18
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35066575207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Single Specialty