Provider Demographics
NPI:1093143877
Name:QUALITY HEALTH & LIFE CLINIC LLC
Entity Type:Organization
Organization Name:QUALITY HEALTH & LIFE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYON
Authorized Official - Middle Name:GABRIEL
Authorized Official - Last Name:BLACKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:239-673-6501
Mailing Address - Street 1:2002 DEL PRADO BLVD S
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-4557
Mailing Address - Country:US
Mailing Address - Phone:230-673-6501
Mailing Address - Fax:
Practice Address - Street 1:2002 DEL PRADO BLVD S
Practice Address - Street 2:SUITE 104
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-4557
Practice Address - Country:US
Practice Address - Phone:230-673-6501
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-14
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH11025111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty