Provider Demographics
NPI:1124252598
Name:BREATH OF LIFE CHIROPRACTIC WELLNESS CENTER P.C.
Entity type:Organization
Organization Name:BREATH OF LIFE CHIROPRACTIC WELLNESS CENTER P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:DENHOLM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:989-619-4709
Mailing Address - Street 1:322 BAY ST
Mailing Address - Street 2:#3
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2489
Mailing Address - Country:US
Mailing Address - Phone:231-622-8828
Mailing Address - Fax:231-622-8829
Practice Address - Street 1:322 BAY ST
Practice Address - Street 2:#3
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2489
Practice Address - Country:US
Practice Address - Phone:231-622-8828
Practice Address - Fax:231-622-8829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-13
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009264111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5195192Medicaid
MI950B01090OtherBCBS OF MICHIGAN
MIM94740002Medicare PIN