Provider Demographics
NPI:1033555289
Name:NEW LIFE CHIROPRACTIC
Entity Type:Organization
Organization Name:NEW LIFE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:R
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:405-382-3635
Mailing Address - Street 1:PO BOX 1301
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:OK
Mailing Address - Zip Code:74818-1301
Mailing Address - Country:US
Mailing Address - Phone:405-382-3635
Mailing Address - Fax:405-382-1037
Practice Address - Street 1:304 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:OK
Practice Address - Zip Code:74868-3428
Practice Address - Country:US
Practice Address - Phone:405-382-3635
Practice Address - Fax:405-382-1037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-15
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3429111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK273268YPRTMedicare PIN