Provider Demographics
NPI:1639224884
Name:LIFETIME WELLNESS FAMILY CHIROPRACTIC, P.C.
Entity Type:Organization
Organization Name:LIFETIME WELLNESS FAMILY CHIROPRACTIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:VANHOOGSTRAAT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:248-628-4886
Mailing Address - Street 1:51 S WASHINGTON ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:OXFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48371-6418
Mailing Address - Country:US
Mailing Address - Phone:248-628-4886
Mailing Address - Fax:248-628-5341
Practice Address - Street 1:51 S WASHINGTON ST
Practice Address - Street 2:SUITE D
Practice Address - City:OXFORD
Practice Address - State:MI
Practice Address - Zip Code:48371-6418
Practice Address - Country:US
Practice Address - Phone:248-628-4886
Practice Address - Fax:248-628-5341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301007079111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M10500Medicare PIN