Provider Demographics
NPI:1285083741
Name:VIBRANT LIFE CHIROPRACTIC LLC
Entity type:Organization
Organization Name:VIBRANT LIFE CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:LAURADELL
Authorized Official - Middle Name:HOGANCAMP
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:270-562-5623
Mailing Address - Street 1:2863 N FRIENDSHIP RD
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-8605
Mailing Address - Country:US
Mailing Address - Phone:270-558-3119
Mailing Address - Fax:
Practice Address - Street 1:2863 N FRIENDSHIP RD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-8605
Practice Address - Country:US
Practice Address - Phone:270-558-3119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5407261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center