Provider Demographics
NPI:1518390293
Name:BOLD LIFE CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:BOLD LIFE CHIROPRACTIC, LLC
Other - Org Name:COMPLETE LIFE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:P
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:334-356-5571
Mailing Address - Street 1:427 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PRATTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36067-3409
Mailing Address - Country:US
Mailing Address - Phone:334-356-5571
Mailing Address - Fax:334-730-0971
Practice Address - Street 1:427 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PRATTVILLE
Practice Address - State:AL
Practice Address - Zip Code:36067-3409
Practice Address - Country:US
Practice Address - Phone:334-356-5571
Practice Address - Fax:334-730-0971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-16
Last Update Date:2019-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1145OtherPTAN