Provider Demographics
NPI:1275844227
Name:LIFE STYLE ENHANCEMENT CENTERS
Entity Type:Organization
Organization Name:LIFE STYLE ENHANCEMENT CENTERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:T
Authorized Official - Last Name:WILDER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:706-837-0405
Mailing Address - Street 1:3206 W POINT RD
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-7545
Mailing Address - Country:US
Mailing Address - Phone:706-837-0405
Mailing Address - Fax:800-648-5256
Practice Address - Street 1:3206 W POINT RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-7545
Practice Address - Country:US
Practice Address - Phone:706-837-0405
Practice Address - Fax:800-648-5256
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-24
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5191111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty