Provider Demographics
NPI:1376615807
Name:LIFE CHIROPRACTIC COLLEGE WEST
Entity Type:Organization
Organization Name:LIFE CHIROPRACTIC COLLEGE WEST
Other - Org Name:LIFE CHIROPRACTIC COLLEGE WEST
Other - Org Type:Other Name
Authorized Official - Title/Position:HEALTH CNTR DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:GAY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:510-780-4000
Mailing Address - Street 1:25001 INDUSTRIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94545-2801
Mailing Address - Country:US
Mailing Address - Phone:510-780-4567
Mailing Address - Fax:510-780-4513
Practice Address - Street 1:25001 INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94545-2801
Practice Address - Country:US
Practice Address - Phone:510-780-4567
Practice Address - Fax:510-780-4567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT05434Medicare UPIN
CAT06345Medicare UPIN
CAU22950Medicare UPIN
CAU55986Medicare UPIN
CAU21515Medicare UPIN
CAV03059Medicare UPIN
V05364Medicare UPIN
U80578Medicare UPIN