Provider Demographics
NPI:1962841569
Name:QUALITY LIFE CHIROPRACTIC & WELLNESS CLINIC LLC
Entity Type:Organization
Organization Name:QUALITY LIFE CHIROPRACTIC & WELLNESS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LEONARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMALOT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:413-209-1475
Mailing Address - Street 1:1272 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104-1153
Mailing Address - Country:US
Mailing Address - Phone:413-209-1475
Mailing Address - Fax:
Practice Address - Street 1:1272 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-1153
Practice Address - Country:US
Practice Address - Phone:413-209-1475
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-18
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3309111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110093148AMedicaid