Provider Demographics
NPI:1306954466
Name:MICHIANA WELLNESS AND LONGEVITY CLINIC, INC.
Entity type:Organization
Organization Name:MICHIANA WELLNESS AND LONGEVITY CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:LYDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC, DABCI, DCBCN
Authorized Official - Phone:574-258-4444
Mailing Address - Street 1:605 W EDISON RD
Mailing Address - Street 2:SUITE G
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-8823
Mailing Address - Country:US
Mailing Address - Phone:574-258-4444
Mailing Address - Fax:574-258-4445
Practice Address - Street 1:605 W EDISON RD
Practice Address - Street 2:SUITE G
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-8823
Practice Address - Country:US
Practice Address - Phone:574-258-4444
Practice Address - Fax:574-258-4445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002006A111NI0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NI0900XChiropractic ProvidersChiropractorInternistGroup - Single Specialty