Provider Demographics
NPI:1841679099
Name:RADIANT LIFE CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:RADIANT LIFE CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:NIGBOR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:608-455-0020
Mailing Address - Street 1:2475 LINEVILLE RD STE B
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54313-7153
Mailing Address - Country:US
Mailing Address - Phone:608-455-0020
Mailing Address - Fax:
Practice Address - Street 1:2475 LINEVILLE RD STE B
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54313-7153
Practice Address - Country:US
Practice Address - Phone:262-751-8857
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-20
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5050-12111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty