Provider Demographics
NPI:1609939230
Name:LIFE CHIROPRACTIC
Entity Type:Organization
Organization Name:LIFE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:COHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-366-4546
Mailing Address - Street 1:134 RITA DR
Mailing Address - Street 2:
Mailing Address - City:CORTLANDT MANOR
Mailing Address - State:NY
Mailing Address - Zip Code:10567-2606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:714 SENECA AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-2895
Practice Address - Country:US
Practice Address - Phone:718-366-4546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX006583-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05893Medicare ID - Type Unspecified