=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821702002
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PURSUITWELL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2023
-----------------------------------------------------
Last Update Date | 01/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14997 ALEXANDER ST
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48154-4051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-968-3599
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14997 ALEXANDER ST
-----------------------------------------------------
City | LIVONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48154-4051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-968-3599
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/RDN
-----------------------------------------------------
Name | KATALEE DEIGHTON
-----------------------------------------------------
Credential | RDN
-----------------------------------------------------
Telephone | 734-968-3599
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 305S00000X
-----------------------------------------------------
Taxonomy Name | Point of Service
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------