Provider Demographics
NPI:1528325669
Name:HEALTH & FITNESS FOR LIFE, LLC
Entity type:Organization
Organization Name:HEALTH & FITNESS FOR LIFE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEHAVEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:269-463-4100
Mailing Address - Street 1:PO BOX 245
Mailing Address - Street 2:
Mailing Address - City:WATERVLIET
Mailing Address - State:MI
Mailing Address - Zip Code:49098-0245
Mailing Address - Country:US
Mailing Address - Phone:269-463-4100
Mailing Address - Fax:
Practice Address - Street 1:7652 RED ARROW HWY
Practice Address - Street 2:
Practice Address - City:WATERVLIET
Practice Address - State:MI
Practice Address - Zip Code:49098-9396
Practice Address - Country:US
Practice Address - Phone:269-463-4100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-13
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2301007097111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M02910Medicare PIN