Provider Demographics
NPI:1891838728
Name:YOUR LIFE CHIROPRACTIC, P.A.
Entity Type:Organization
Organization Name:YOUR LIFE CHIROPRACTIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAUDIE
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:LOUISIANA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-682-0611
Mailing Address - Street 1:103 CENTER DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-2957
Mailing Address - Country:US
Mailing Address - Phone:763-682-0611
Mailing Address - Fax:763-682-0788
Practice Address - Street 1:103 CENTER DR
Practice Address - Street 2:SUITE 200
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-2957
Practice Address - Country:US
Practice Address - Phone:763-682-0611
Practice Address - Fax:763-682-0788
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN581111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN62M57DEOtherBLUE CROSS BLUE SHIELD
MNC03354Medicare ID - Type UnspecifiedGROUP NUMBER