Provider Demographics
NPI:1740778422
Name:FIT FOR LIFE CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:FIT FOR LIFE CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:KRUCKENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:952-250-4591
Mailing Address - Street 1:312 E HOLLY BLVD
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:SD
Mailing Address - Zip Code:57005-1240
Mailing Address - Country:US
Mailing Address - Phone:605-254-7735
Mailing Address - Fax:
Practice Address - Street 1:312 E HOLLY BLVD
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:SD
Practice Address - Zip Code:57005-1240
Practice Address - Country:US
Practice Address - Phone:605-254-7735
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-27
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty