1619703568 NPI number — EXTRAORDINARY LIFE CHIROPRACTIC LLC

Table of content: KELLI LYNN DOLBEE FNP (NPI 1619549938)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619703568 NPI number — EXTRAORDINARY LIFE CHIROPRACTIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EXTRAORDINARY LIFE 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:
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:
1619703568
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9910 MELBA LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WHITESVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42378-9418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-993-5398
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
303 E 14TH ST STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OWENSBORO
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42303-3056
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-297-0028
Provider Business Practice Location Address Fax Number:
270-297-0026
Provider Enumeration Date:
09/09/2024

Additional Information

Authorized Official

Authorized Official Last Name:
PERRY
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
270-993-5398

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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