Provider Demographics
NPI:1578736567
Name:LIFETIME FAMILY WELLNESS INC
Entity Type:Organization
Organization Name:LIFETIME FAMILY WELLNESS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JIM BOB
Authorized Official - Middle Name:
Authorized Official - Last Name:HAGGERTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:817-428-9595
Mailing Address - Street 1:1813 HARWOOD CT
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76054-3190
Mailing Address - Country:US
Mailing Address - Phone:817-428-9595
Mailing Address - Fax:817-428-9451
Practice Address - Street 1:1813 HARWOOD CT
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054-3190
Practice Address - Country:US
Practice Address - Phone:817-428-9595
Practice Address - Fax:817-428-9451
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-10
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9744111N00000X
TX10827111N00000X
TX10073111NP0017X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No111NP0017XChiropractic ProvidersChiropractorPediatric ChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX610524Medicare PIN