1669540605 NPI number — LIFELINE CHIROPRACTIC, PLLC.

Table of content: (NPI 1669540605)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669540605 NPI number — LIFELINE CHIROPRACTIC, PLLC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIFELINE CHIROPRACTIC, PLLC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669540605
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/18/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2487
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORNELIUS
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28031-2487
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-655-8930
Provider Business Mailing Address Fax Number:
704-655-8932

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19824 W CATAWBA AVE STE E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORNELIUS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28031-4046
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-655-8930
Provider Business Practice Location Address Fax Number:
704-655-8932
Provider Enumeration Date:
11/30/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
CHANDLER
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
WAYNE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
704-655-8930

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2373 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 89085N9 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".