Provider Demographics
NPI:1396563821
Name:LIFE IV THERAPY PLLC
Entity type:Organization
Organization Name:LIFE IV THERAPY PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:517-273-3210
Mailing Address - Street 1:1325 N MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-1721
Mailing Address - Country:US
Mailing Address - Phone:517-273-3210
Mailing Address - Fax:
Practice Address - Street 1:1325 N MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1721
Practice Address - Country:US
Practice Address - Phone:517-273-3210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-02
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RB0002XAllopathic & Osteopathic PhysiciansInternal MedicineObesity MedicineGroup - Multi-Specialty