Provider Demographics
NPI:1205265022
Name:CHIRO LIFE CLINIC LLC
Entity type:Organization
Organization Name:CHIRO LIFE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KHAM SING
Authorized Official - Middle Name:
Authorized Official - Last Name:XIONG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-203-0477
Mailing Address - Street 1:860 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-1172
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1052 WITZEL AVE
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54902-5720
Practice Address - Country:US
Practice Address - Phone:920-203-0477
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-02
Last Update Date:2013-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4928-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty