Provider Demographics
NPI:1508877978
Name:WALSEMANN CHIROPRACTIC LIFE CENTER, P.A.
Entity Type:Organization
Organization Name:WALSEMANN CHIROPRACTIC LIFE CENTER, P.A.
Other - Org Name:WALSEMANN-LANZARA CHIROPRACTIC LIFE CENTER, P.A.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:WALSEMANN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:603-542-7726
Mailing Address - Street 1:39 MRYTLE ST
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:NH
Mailing Address - Zip Code:03743-2547
Mailing Address - Country:US
Mailing Address - Phone:603-542-7726
Mailing Address - Fax:603-542-0471
Practice Address - Street 1:39 MRYTLE ST
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:NH
Practice Address - Zip Code:03743-2547
Practice Address - Country:US
Practice Address - Phone:603-542-7726
Practice Address - Fax:603-542-0471
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH728-0704111N00000X
111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH80358615Medicaid
NH80358615Medicaid