Provider Demographics
NPI:1265787683
Name:LIFE CHIROPRACTIC
Entity type:Organization
Organization Name:LIFE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:R
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:801-229-1122
Mailing Address - Street 1:309 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84057-4747
Mailing Address - Country:US
Mailing Address - Phone:801-229-1122
Mailing Address - Fax:
Practice Address - Street 1:309 N STATE ST
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84057-4747
Practice Address - Country:US
Practice Address - Phone:801-229-1122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-23
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT281021-1202261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center