1629591979 NPI number — LIFE REFINED CHIROPRACTIC, LLC

Table of content: (NPI 1629591979)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629591979 NPI number — LIFE REFINED CHIROPRACTIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
N/A
Provider Organization Name:
LIFE REFINED CHIROPRACTIC, LLC
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:
LIFE REFINED CHIROPRACTIC
Provider Other Organization Name Type Code:
3
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:
1629591979
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
14297 BERGEN BLVD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NOBLESVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46060-3383
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-674-8857
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14214 VALLEY CREST CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FISHERS
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
(701) 340-7234
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/19/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BLUME
Authorized Official First Name:
STACI
Authorized Official Middle Name:
JEAN
Authorized Official Title or Position:
PARTNER
Authorized Official Telephone Number:
317-674-8857

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  08002871A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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