Healthcare Provider Details

I. General information

NPI: 1215195466
Provider Name (Legal Business Name): HEALTHY HABITS WELLNESS CENTER LAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2008
Last Update Date: 05/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 STOLLINGS AVE STE 3
LOGAN WV
25601-4035
US

IV. Provider business mailing address

140 STOLLINGS AVE STE 3
LOGAN WV
25601-4035
US

V. Phone/Fax

Practice location:
  • Phone: 304-752-4594
  • Fax: 304-752-5629
Mailing address:
  • Phone: 304-752-4594
  • Fax: 304-752-5629

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: DR. JON M MILLER
Title or Position: PRESIDENT
Credential: DO
Phone: 304-752-4594