=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912726811
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFELINE INTERVENTIONAL THERAPEUTICS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2024
-----------------------------------------------------
Last Update Date | 12/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1179 E PARIS AVE SE STE 100
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49546-3682
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-400-5433
-----------------------------------------------------
Fax | 616-360-2034
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1179 E PARIS AVE SE STE 100
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49546-3682
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-400-5433
-----------------------------------------------------
Fax | 616-360-2034
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER/PHYSICIAN ASSISTANT
-----------------------------------------------------
Name | MR. WILLIAM PAUL VANLONKHUYZEN
-----------------------------------------------------
Credential | PA-C
-----------------------------------------------------
Telephone | 616-400-5433
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084A0401X
-----------------------------------------------------
Taxonomy Name | Addiction Medicine (Psychiatry & Neurology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P2900X
-----------------------------------------------------
Taxonomy Name | Pain Medicine (Psychiatry & Neurology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------