Provider Demographics
NPI:1699368746
Name:LIFE FAMILY CHIROPRACTIC OF PORTLAND, LLC
Entity type:Organization
Organization Name:LIFE FAMILY CHIROPRACTIC OF PORTLAND, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:860-384-0494
Mailing Address - Street 1:234 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:CT
Mailing Address - Zip Code:06480-1861
Mailing Address - Country:US
Mailing Address - Phone:860-342-7277
Mailing Address - Fax:860-342-7281
Practice Address - Street 1:234 MAIN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:CT
Practice Address - Zip Code:06480-1861
Practice Address - Country:US
Practice Address - Phone:860-342-7277
Practice Address - Fax:860-342-7281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-18
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty