Provider Demographics
NPI:1639590961
Name:BUMALAFA
Entity Type:Organization
Organization Name:BUMALAFA
Other - Org Name:LIFETIME FAMILY WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:BURKELY
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:435-851-6223
Mailing Address - Street 1:PO BOX 9641
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84409-0641
Mailing Address - Country:US
Mailing Address - Phone:801-479-3200
Mailing Address - Fax:
Practice Address - Street 1:5319 ADAMS AVE PKWY
Practice Address - Street 2:STE D
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-4773
Practice Address - Country:US
Practice Address - Phone:801-479-3200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-06
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7564602-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty