Provider Demographics
NPI:1083753396
Name:NEW LIFE CHIROPRACTIC INC PS
Entity Type:Organization
Organization Name:NEW LIFE CHIROPRACTIC INC PS
Other - Org Name:NEW LIFE CHIROPRACTIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRICE
Authorized Official - Middle Name:P
Authorized Official - Last Name:KOVARIK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:425-776-8303
Mailing Address - Street 1:19503 56TH AVE W
Mailing Address - Street 2:STE A
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-5225
Mailing Address - Country:US
Mailing Address - Phone:425-776-8303
Mailing Address - Fax:425-776-8363
Practice Address - Street 1:19503 56TH AVE W
Practice Address - Street 2:STE A
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-5225
Practice Address - Country:US
Practice Address - Phone:425-776-8303
Practice Address - Fax:425-776-8363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00034176111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAU99360Medicare UPIN
WAPENDINGMedicare ID - Type Unspecified