Provider Demographics
NPI:1770864431
Name:LIFESPAN CHIROPRACTIC PA
Entity Type:Organization
Organization Name:LIFESPAN CHIROPRACTIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KATY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:HEILMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:952-432-4222
Mailing Address - Street 1:7493 147TH ST W
Mailing Address - Street 2:SUITE 203
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-4505
Mailing Address - Country:US
Mailing Address - Phone:952-432-4222
Mailing Address - Fax:952-432-4225
Practice Address - Street 1:7493 147TH ST W
Practice Address - Street 2:SUITE 203
Practice Address - City:APPLE VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55124-4505
Practice Address - Country:US
Practice Address - Phone:952-432-4222
Practice Address - Fax:952-432-4225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-07
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3437261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN7815204-00Medicaid
MN7815204-00Medicaid