Provider Demographics
NPI:1508031782
Name:LIFE CHIROPRACTIC, PS
Entity Type:Organization
Organization Name:LIFE CHIROPRACTIC, PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:HARDY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:253-874-4141
Mailing Address - Street 1:34507 PACIFIC HWY S
Mailing Address - Street 2:STE 4
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6879
Mailing Address - Country:US
Mailing Address - Phone:253-874-4141
Mailing Address - Fax:253-874-3601
Practice Address - Street 1:34507 PACIFIC HWY S
Practice Address - Street 2:STE 4
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6879
Practice Address - Country:US
Practice Address - Phone:253-874-4141
Practice Address - Fax:253-874-3601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-28
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00001214111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty