Provider Demographics
NPI:1073773388
Name:CHIROPRACTIC LIFE CENTER
Entity Type:Organization
Organization Name:CHIROPRACTIC LIFE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:CLAY
Authorized Official - Last Name:BISHOP
Authorized Official - Suffix:
Authorized Official - Credentials:BS,DC
Authorized Official - Phone:321-633-1400
Mailing Address - Street 1:400 BARTON BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-2706
Mailing Address - Country:US
Mailing Address - Phone:321-633-1400
Mailing Address - Fax:321-637-7057
Practice Address - Street 1:400 BARTON BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2706
Practice Address - Country:US
Practice Address - Phone:321-633-1400
Practice Address - Fax:321-637-7057
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH7721111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL55880Medicaid
5954350001OtherPTAN
FLU82755Medicare UPIN
FL55880Medicaid