=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396289120
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEXT LEVEL UP HEALTH & WELLNESS INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2016
-----------------------------------------------------
Last Update Date | 03/07/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 28423 PARKWOOD ST
-----------------------------------------------------
City | INKSTER
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48141-1669
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-618-7561
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27436 AVONDALE ST
-----------------------------------------------------
City | INKSTER
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48141-1787
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-664-4729
-----------------------------------------------------
Fax | 734-895-6230
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AUTHORIZED OFFICIAL
-----------------------------------------------------
Name | CHIFFON E MURRAY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-618-7561
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------