Provider Demographics
NPI:1437666914
Name:AUTHENTIC LIFE
Entity Type:Organization
Organization Name:AUTHENTIC LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIEF CLINICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGIA
Authorized Official - Middle Name:J
Authorized Official - Last Name:NAB
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:913-562-4621
Mailing Address - Street 1:11960 WEST 119TH STREET
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66213
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11960 WEST 119TH STREET
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66213
Practice Address - Country:US
Practice Address - Phone:913-563-4621
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-05
Last Update Date:2018-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04604111N00000X
KS04640111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No111NN1001XChiropractic ProvidersChiropractorNutritionGroup - Single Specialty