Provider Demographics
NPI:1912478819
Name:HEALTHY LIFESTYLE MEDICINE
Entity Type:Organization
Organization Name:HEALTHY LIFESTYLE MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN KIRK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:307-823-2968
Mailing Address - Street 1:6015 SYCAMORE RD
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-4347
Mailing Address - Country:US
Mailing Address - Phone:307-823-2968
Mailing Address - Fax:
Practice Address - Street 1:6015 SYCAMORE RD
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-4347
Practice Address - Country:US
Practice Address - Phone:307-823-2968
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-17
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No2083B0002XAllopathic & Osteopathic PhysiciansPreventive MedicineObesity MedicineGroup - Multi-Specialty