Provider Demographics
NPI:1235311721
Name:FIRE OF LIFE CHIROPRACTIC PLLC
Entity Type:Organization
Organization Name:FIRE OF LIFE CHIROPRACTIC PLLC
Other - Org Name:FIRE OF LIFE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KURT
Authorized Official - Middle Name:VANESSA
Authorized Official - Last Name:EDEKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-608-9121
Mailing Address - Street 1:1200 LAKEWAY DR
Mailing Address - Street 2:17B
Mailing Address - City:LAKEWAY
Mailing Address - State:TX
Mailing Address - Zip Code:78734-4400
Mailing Address - Country:US
Mailing Address - Phone:512-608-9121
Mailing Address - Fax:512-608-9121
Practice Address - Street 1:1200 LAKEWAY DR
Practice Address - Street 2:17B
Practice Address - City:LAKEWAY
Practice Address - State:TX
Practice Address - Zip Code:78734-4400
Practice Address - Country:US
Practice Address - Phone:512-608-9121
Practice Address - Fax:512-608-9121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-27
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9962111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00641YOtherMEDICARE LEGACY #
1235311721OtherGROUP NPI
TX1003096975OtherINDIVIDUAL NPI
TX1003096975OtherINDIVIDUAL NPI