Healthcare Provider Details

I. General information

NPI: 1831305333
Provider Name (Legal Business Name): JUNIOR YOGI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 08/29/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2269 BRIDLE TRL
METAMORA MI
48455-9270
US

IV. Provider business mailing address

2269 BRIDLE TRL
METAMORA MI
48455-9270
US

V. Phone/Fax

Practice location:
  • Phone: 586-764-0837
  • Fax: 810-724-8872
Mailing address:
  • Phone: 586-764-0837
  • Fax: 810-724-8872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINA MARIE EVANS
Title or Position: YOGA THERAPIST
Credential: MPT
Phone: 586-764-0837