Provider Demographics
NPI:1750771200
Name:LIVING4LIFE WELLNESSLLC
Entity type:Organization
Organization Name:LIVING4LIFE WELLNESSLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/WELLNESS SPECIALIST
Authorized Official - Prefix:MR
Authorized Official - First Name:DONISS
Authorized Official - Middle Name:L
Authorized Official - Last Name:HICKS
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:313-618-7454
Mailing Address - Street 1:PO BOX 241603
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-5603
Mailing Address - Country:US
Mailing Address - Phone:313-618-7454
Mailing Address - Fax:
Practice Address - Street 1:11085 MCKINNEY ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224-1112
Practice Address - Country:US
Practice Address - Phone:313-618-7454
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-04
Last Update Date:2015-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI812531133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, MetabolicGroup - Single Specialty