Healthcare Provider Details

I. General information

NPI: 1821961087
Provider Name (Legal Business Name): UNEVEN LOTUS YOGA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/24/2025
Last Update Date: 09/29/2025
Certification Date: 09/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 48TH ST SE
KENTWOOD MI
49548-4407
US

IV. Provider business mailing address

5935 CRESTMOOR DR SE
KENTWOOD MI
49508-6511
US

V. Phone/Fax

Practice location:
  • Phone: 616-805-9195
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name: ANGELA GOLLADAY
Title or Position: REGISTERED YOGA TEACHER
Credential: ERYT200, YACEP
Phone: 616-805-9195