Provider Demographics
NPI:1578756201
Name:NEW LIFE SPINE CENTER LLC
Entity Type:Organization
Organization Name:NEW LIFE SPINE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:BAUR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:419-724-5433
Mailing Address - Street 1:1331 CONANT STREET #104
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537
Mailing Address - Country:US
Mailing Address - Phone:419-724-5433
Mailing Address - Fax:419-720-6994
Practice Address - Street 1:1331 CONANT STREET #104
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537
Practice Address - Country:US
Practice Address - Phone:419-724-5433
Practice Address - Fax:419-720-6994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-27
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3371111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2483227Medicaid
OH9360541OtherMEDICARE GROUP NUMBER
OH9360541OtherMEDICARE GROUP NUMBER