1235311721 NPI number — FIRE OF LIFE CHIROPRACTIC PLLC

Table of content: (NPI 1235311721)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235311721 NPI number — FIRE OF LIFE CHIROPRACTIC PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIRE OF LIFE 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:
6
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:
1235311721
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/31/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 LAKEWAY DR
Provider Second Line Business Mailing Address:
17B
Provider Business Mailing Address City Name:
LAKEWAY
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78734-4400
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-608-9121
Provider Business Mailing Address Fax Number:
512-608-9121

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 LAKEWAY DR
Provider Second Line Business Practice Location Address:
17B
Provider Business Practice Location Address City Name:
LAKEWAY
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78734-4400
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-608-9121
Provider Business Practice Location Address Fax Number:
512-608-9121
Provider Enumeration Date:
11/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
EDEKER
Authorized Official First Name:
KURT
Authorized Official Middle Name:
VANESSA
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
512-608-9121

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  9962 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00641Y . This is a "MEDICARE LEGACY #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1235311721 . This is a "GROUP NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1003096975 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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