Provider Demographics
NPI: | 1922752807 |
---|---|
Name: | LIFE CLINIC OF GA PC |
Entity Type: | Organization |
Organization Name: | LIFE CLINIC OF GA PC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | |
Authorized Official - First Name: | REZA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | ALIZADEH |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 612-868-6894 |
Mailing Address - Street 1: | PO BOX 549 |
Mailing Address - Street 2: | |
Mailing Address - City: | CHANHASSEN |
Mailing Address - State: | MN |
Mailing Address - Zip Code: | 55317-0549 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 14200 HIGHWAY 92 |
Practice Address - Street 2: | |
Practice Address - City: | WOODSTOCK |
Practice Address - State: | GA |
Practice Address - Zip Code: | 30188-7139 |
Practice Address - Country: | US |
Practice Address - Phone: | 952-229-7464 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2022-02-09 |
Last Update Date: | 2022-02-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 111N00000X | Chiropractic Providers | Chiropractor | Group - Multi-Specialty | |
No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty |