Healthcare Provider Details

I. General information

NPI: 1750771200
Provider Name (Legal Business Name): LIVING4LIFE WELLNESSLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2015
Last Update Date: 02/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11085 MCKINNEY ST
DETROIT MI
48224-1112
US

IV. Provider business mailing address

PO BOX 241603
DETROIT MI
48224-5603
US

V. Phone/Fax

Practice location:
  • Phone: 313-618-7454
  • Fax:
Mailing address:
  • Phone: 313-618-7454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number812531
License Number StateMI

VIII. Authorized Official

Name: MR. DONISS L HICKS
Title or Position: PRESIDENT/WELLNESS SPECIALIST
Credential: RD
Phone: 313-618-7454