Healthcare Provider Details

I. General information

NPI: 1831922350
Provider Name (Legal Business Name): MICHAEL CHARRON MICKENS HEALTH COACH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2024
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8708 BIG TREE CIR APT G
LOUISVILLE KY
40220-5856
US

IV. Provider business mailing address

8708 BIG TREE CIR APT G
LOUISVILLE KY
40220-5856
US

V. Phone/Fax

Practice location:
  • Phone: 269-815-2077
  • Fax:
Mailing address:
  • Phone: 269-815-2077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License NumberNA
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: