Provider Demographics
NPI:1063666444
Name:BRILLIANT LIFE CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:BRILLIANT LIFE CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:253-383-0577
Mailing Address - Street 1:708 BROADWAY STE 403
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-3781
Mailing Address - Country:US
Mailing Address - Phone:253-383-0577
Mailing Address - Fax:253-383-0574
Practice Address - Street 1:708 BROADWAY STE 403
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402
Practice Address - Country:US
Practice Address - Phone:253-383-0577
Practice Address - Fax:253-383-0574
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-11
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034780111N00000X
WACH00034834111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty