Provider Demographics
NPI:1912726811
Name:LIFELINE INTERVENTIONAL THERAPEUTICS, PLLC
Entity type:Organization
Organization Name:LIFELINE INTERVENTIONAL THERAPEUTICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/PHYSICIAN ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:VANLONKHUYZEN
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:616-400-5433
Mailing Address - Street 1:1179 E PARIS AVE SE STE 100
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-3682
Mailing Address - Country:US
Mailing Address - Phone:616-400-5433
Mailing Address - Fax:616-360-2034
Practice Address - Street 1:1179 E PARIS AVE SE STE 100
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3682
Practice Address - Country:US
Practice Address - Phone:616-400-5433
Practice Address - Fax:616-360-2034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-08
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Multi-Specialty
No2084P2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPain MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty