Provider Demographics
NPI:1376897397
Name:LIFETIME WELLNESS CLINIC OF CHIROPRACTIC PC
Entity Type:Organization
Organization Name:LIFETIME WELLNESS CLINIC OF CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:HUFSTADER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:402-994-2030
Mailing Address - Street 1:105 WEST E STREET
Mailing Address - Street 2:PO BOX 306
Mailing Address - City:ELMWOOD
Mailing Address - State:NE
Mailing Address - Zip Code:68349
Mailing Address - Country:US
Mailing Address - Phone:402-994-2030
Mailing Address - Fax:402-994-2101
Practice Address - Street 1:105 W E ST
Practice Address - Street 2:
Practice Address - City:ELMWOOD
Practice Address - State:NE
Practice Address - Zip Code:68349-6113
Practice Address - Country:US
Practice Address - Phone:402-994-2030
Practice Address - Fax:402-994-2101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1488111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty