Provider Demographics
NPI:1992007025
Name:THE LIFE HOUSE CHIROPRACTIC PLLC
Entity Type:Organization
Organization Name:THE LIFE HOUSE CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSH
Authorized Official - Middle Name:
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:212-328-6876
Mailing Address - Street 1:19 E 71ST ST
Mailing Address - Street 2:SUITE 5A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4119
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19 E 71ST ST
Practice Address - Street 2:SUITE 5A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4119
Practice Address - Country:US
Practice Address - Phone:212-876-3286
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-22
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011928-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty