Provider Demographics
NPI:1033557921
Name:CHIROPRACTIC LIFE CENTER LLC
Entity Type:Organization
Organization Name:CHIROPRACTIC LIFE CENTER LLC
Other - Org Name:DR, JAMES B CULVEYHOUSE SR DC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:B
Authorized Official - Last Name:CULVEYHOUSE
Authorized Official - Suffix:SR
Authorized Official - Credentials:DC
Authorized Official - Phone:228-864-6159
Mailing Address - Street 1:1900 PASS RD
Mailing Address - Street 2:STE D
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-5100
Mailing Address - Country:US
Mailing Address - Phone:228-864-6159
Mailing Address - Fax:228-864-3186
Practice Address - Street 1:1900 PASS RD
Practice Address - Street 2:STE D
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-5100
Practice Address - Country:US
Practice Address - Phone:228-864-6159
Practice Address - Fax:228-864-3186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-12
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS0356111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00119478Medicaid
MS00119478Medicaid