Provider Demographics
NPI:1225309248
Name:PURE LIFE CHIROPRACTIC AND WELLNESS CENTER, LTD
Entity Type:Organization
Organization Name:PURE LIFE CHIROPRACTIC AND WELLNESS CENTER, LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:320-864-6249
Mailing Address - Street 1:920 10TH ST E
Mailing Address - Street 2:
Mailing Address - City:GLENCOE
Mailing Address - State:MN
Mailing Address - Zip Code:55336-2301
Mailing Address - Country:US
Mailing Address - Phone:320-864-6249
Mailing Address - Fax:320-864-6243
Practice Address - Street 1:920 10TH ST E
Practice Address - Street 2:
Practice Address - City:GLENCOE
Practice Address - State:MN
Practice Address - Zip Code:55336-2301
Practice Address - Country:US
Practice Address - Phone:320-864-6249
Practice Address - Fax:320-864-6243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5603305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service