Provider Demographics
NPI:1598820821
Name:LIFESTYLES CHIROPRACTIC
Entity Type:Organization
Organization Name:LIFESTYLES CHIROPRACTIC
Other - Org Name:LIFESTYLES CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:E
Authorized Official - Last Name:WICKMANN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:239-334-9355
Mailing Address - Street 1:11300 LINDBERGH BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33913-8827
Mailing Address - Country:US
Mailing Address - Phone:239-334-9355
Mailing Address - Fax:239-334-9358
Practice Address - Street 1:11300 LINDBERGH BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33913-8827
Practice Address - Country:US
Practice Address - Phone:239-334-9355
Practice Address - Fax:239-334-9358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-27
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9155111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5882480001Medicare NSC