Provider Demographics
NPI:1639363310
Name:LIFE CHIROPRACTIC CENTER PA
Entity Type:Organization
Organization Name:LIFE CHIROPRACTIC CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:NATHANIEL
Authorized Official - Last Name:RUKEYSER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:772-398-8888
Mailing Address - Street 1:1230 SE PORT ST LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-5330
Mailing Address - Country:US
Mailing Address - Phone:772-398-8888
Mailing Address - Fax:
Practice Address - Street 1:1230 SE PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5330
Practice Address - Country:US
Practice Address - Phone:772-398-8888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-05
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8717111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL74769OtherBLUE CROSS BLUE SHIELD
FL381887000Medicaid
FL74769Medicare PIN