Provider Demographics
NPI:1104337211
Name:EAST WEST LIFE SOLUTIONS INC.
Entity type:Organization
Organization Name:EAST WEST LIFE SOLUTIONS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:LAMBROS
Authorized Official - Middle Name:NICHOLAS
Authorized Official - Last Name:KOTTALIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:810-522-3095
Mailing Address - Street 1:14543 BLUE HERON DR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430-3268
Mailing Address - Country:US
Mailing Address - Phone:810-522-3095
Mailing Address - Fax:
Practice Address - Street 1:221 S MILL ST
Practice Address - Street 2:
Practice Address - City:CLIO
Practice Address - State:MI
Practice Address - Zip Code:48420-2324
Practice Address - Country:US
Practice Address - Phone:810-522-3095
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-16
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009759111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1134421019Medicaid