Healthcare Provider Details

I. General information

NPI: 1396563821
Provider Name (Legal Business Name): LIFE IV THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2024
Last Update Date: 02/26/2026
Certification Date: 02/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5433 S OCCIDENTAL RD STE C
TECUMSEH MI
49286-9782
US

IV. Provider business mailing address

5433 S OCCIDENTAL RD STE C
TECUMSEH MI
49286-9782
US

V. Phone/Fax

Practice location:
  • Phone: 517-273-3210
  • Fax: 734-418-9068
Mailing address:
  • Phone: 517-273-3210
  • Fax: 734-418-9068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RB0002X
TaxonomyObesity Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: JUSTIN HENRY
Title or Position: CEO
Credential: RN
Phone: 517-273-3210