Provider Demographics
NPI:1720575178
Name:LIFE CLINIC OF NJ DC PA
Entity Type:Organization
Organization Name:LIFE CLINIC OF NJ DC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DC
Authorized Official - Prefix:DR
Authorized Official - First Name:REZA
Authorized Official - Middle Name:POUR
Authorized Official - Last Name:ALIZADEH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:612-868-6894
Mailing Address - Street 1:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-0549
Mailing Address - Country:US
Mailing Address - Phone:612-868-6894
Mailing Address - Fax:
Practice Address - Street 1:7 FORRESTAL ROAD S
Practice Address - Street 2:
Practice Address - City:PLAINSBOROUGH
Practice Address - State:NJ
Practice Address - Zip Code:08536
Practice Address - Country:US
Practice Address - Phone:612-868-6894
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-20
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00735800111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty