Provider Demographics
NPI:1891913927
Name:CAFE OF LIFE FENTON, LLC
Entity Type:Organization
Organization Name:CAFE OF LIFE FENTON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PEABODY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:810-629-6023
Mailing Address - Street 1:114 W CAROLINE ST
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-3802
Mailing Address - Country:US
Mailing Address - Phone:810-629-6023
Mailing Address - Fax:810-629-6024
Practice Address - Street 1:114 W CAROLINE ST
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-3802
Practice Address - Country:US
Practice Address - Phone:810-629-6023
Practice Address - Fax:810-629-6024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008978111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1000662Medicaid