Provider Demographics
NPI:1164915120
Name:VITALIFE CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:VITALIFE CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:720-900-5251
Mailing Address - Street 1:1020 KEN PRATT BLVD UNIT D
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-6376
Mailing Address - Country:US
Mailing Address - Phone:720-900-5251
Mailing Address - Fax:
Practice Address - Street 1:1020 KEN PRATT BLVD UNIT D
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501
Practice Address - Country:US
Practice Address - Phone:720-900-5251
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-13
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty