Provider Demographics
NPI:1376069476
Name:VITAL LIFE CHIROPRACTIC
Entity Type:Organization
Organization Name:VITAL LIFE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RONNIE
Authorized Official - Middle Name:EARL
Authorized Official - Last Name:BOLAR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:334-321-7275
Mailing Address - Street 1:865 THORNTON RD STE B
Mailing Address - Street 2:
Mailing Address - City:LITHIA SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30122-2607
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:865 THORNTON RD STE B
Practice Address - Street 2:
Practice Address - City:LITHIA SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30122-2607
Practice Address - Country:US
Practice Address - Phone:334-321-7275
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-21
Last Update Date:2017-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR009917111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty