Provider Demographics
NPI:1003133364
Name:LIFE ENERGY CHIROPRACTIC & WELLNESS, P.A.
Entity Type:Organization
Organization Name:LIFE ENERGY CHIROPRACTIC & WELLNESS, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:NATHAN
Authorized Official - Last Name:JAEGER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:701-356-5433
Mailing Address - Street 1:4955 17TH AVE S
Mailing Address - Street 2:SUITE 108
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3372
Mailing Address - Country:US
Mailing Address - Phone:701-356-5433
Mailing Address - Fax:701-364-2675
Practice Address - Street 1:4955 17TH AVE S
Practice Address - Street 2:SUITE 108
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3372
Practice Address - Country:US
Practice Address - Phone:701-356-5433
Practice Address - Fax:701-364-2675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-27
Last Update Date:2010-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND857111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty