Provider Demographics
NPI:1437327533
Name:LIFE CHIROPRACTIC PC
Entity Type:Organization
Organization Name:LIFE CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:STACKIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:563-582-0300
Mailing Address - Street 1:2454 MEINEN CT
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002
Mailing Address - Country:US
Mailing Address - Phone:563-582-0300
Mailing Address - Fax:
Practice Address - Street 1:2454 MEINEN CT
Practice Address - Street 2:
Practice Address - City:DUBUQUE
Practice Address - State:IA
Practice Address - Zip Code:52002
Practice Address - Country:US
Practice Address - Phone:563-582-0300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-12
Last Update Date:2011-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06739111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0469346Medicaid
IA0469346Medicaid