Provider Demographics
NPI:1629278791
Name:LIFE CHIROPRACTIC CENTER PA
Entity Type:Organization
Organization Name:LIFE CHIROPRACTIC CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-457-1551
Mailing Address - Street 1:605 N SHETLAND CT
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5447
Mailing Address - Country:US
Mailing Address - Phone:208-457-1551
Mailing Address - Fax:208-457-1756
Practice Address - Street 1:605 N SHETLAND CT
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-5447
Practice Address - Country:US
Practice Address - Phone:208-457-1551
Practice Address - Fax:208-457-1756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA 767111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1378621Medicare PIN