Provider Demographics
NPI:1699428185
Name:PURE LIFE CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:PURE LIFE CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELBY
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-750-8583
Mailing Address - Street 1:7149 WHITESTOWN PKWY
Mailing Address - Street 2:
Mailing Address - City:ZIONSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46077-7626
Mailing Address - Country:US
Mailing Address - Phone:317-750-8583
Mailing Address - Fax:
Practice Address - Street 1:7149 WHITESTOWN PKWY
Practice Address - Street 2:
Practice Address - City:ZIONSVILLE
Practice Address - State:IN
Practice Address - Zip Code:46077-7626
Practice Address - Country:US
Practice Address - Phone:219-964-1188
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-03
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty