Provider Demographics
NPI:1861504383
Name:PRIME LIFE CHIROPRACTIC
Entity Type:Organization
Organization Name:PRIME LIFE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:OFFICE MANAGER
Authorized Official - Phone:972-424-2225
Mailing Address - Street 1:2504 K AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75074-5340
Mailing Address - Country:US
Mailing Address - Phone:972-424-2225
Mailing Address - Fax:972-424-7709
Practice Address - Street 1:2504 K AVE
Practice Address - Street 2:SUITE 500
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75074-5340
Practice Address - Country:US
Practice Address - Phone:972-424-2225
Practice Address - Fax:972-424-7709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF006625111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXJ10AOtherBLUE CROSS BLUE SHIELD
TX00878WMedicare ID - Type UnspecifiedGROUP NUMBER