Provider Demographics
NPI:1891249942
Name:LIFETIME CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:LIFETIME CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:480-633-3151
Mailing Address - Street 1:PO BOX 1697
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-1837
Mailing Address - Country:US
Mailing Address - Phone:480-633-3151
Mailing Address - Fax:480-383-6076
Practice Address - Street 1:235 E WARNER RD
Practice Address - Street 2:STE B104
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-2972
Practice Address - Country:US
Practice Address - Phone:480-633-3151
Practice Address - Fax:480-383-6076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-06
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8136111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty