Healthcare Provider Details

I. General information

NPI: 1912726811
Provider Name (Legal Business Name): LIFELINE INTERVENTIONAL THERAPEUTICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2024
Last Update Date: 12/06/2024
Certification Date: 12/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1179 E PARIS AVE SE STE 100
GRAND RAPIDS MI
49546-3682
US

IV. Provider business mailing address

1179 E PARIS AVE SE STE 100
GRAND RAPIDS MI
49546-3682
US

V. Phone/Fax

Practice location:
  • Phone: 616-400-5433
  • Fax: 616-360-2034
Mailing address:
  • Phone: 616-400-5433
  • Fax: 616-360-2034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P2900X
TaxonomyPain Medicine (Psychiatry & Neurology) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM PAUL VANLONKHUYZEN
Title or Position: PARTNER/PHYSICIAN ASSISTANT
Credential: PA-C
Phone: 616-400-5433