Provider Demographics
NPI:1538112677
Name:CHIROPRACTIC LIFE CENTER PC
Entity Type:Organization
Organization Name:CHIROPRACTIC LIFE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-454-5433
Mailing Address - Street 1:305 NW ENGLEWOOD CT
Mailing Address - Street 2:SUITE: 200
Mailing Address - City:GLADSTONE
Mailing Address - State:MO
Mailing Address - Zip Code:64118-4072
Mailing Address - Country:US
Mailing Address - Phone:816-454-5433
Mailing Address - Fax:816-454-8455
Practice Address - Street 1:305 NW ENGLEWOOD CT
Practice Address - Street 2:SUITE: 200
Practice Address - City:GLADSTONE
Practice Address - State:MO
Practice Address - Zip Code:64118-4072
Practice Address - Country:US
Practice Address - Phone:816-454-5433
Practice Address - Fax:816-454-8455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO005977111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U29742Medicare UPIN
D510893Medicare ID - Type Unspecified
MOD510000Medicare PIN