Provider Demographics
NPI:1962734889
Name:LIFETIME WELLNESS CHIROPRACTIC PLLC
Entity type:Organization
Organization Name:LIFETIME WELLNESS CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENNAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-552-5555
Mailing Address - Street 1:2225 TETON PLZ STE B
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6494
Mailing Address - Country:US
Mailing Address - Phone:208-552-5555
Mailing Address - Fax:
Practice Address - Street 1:2225 TETON PLZ STE B
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6494
Practice Address - Country:US
Practice Address - Phone:208-552-5555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-03
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-1397111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1962734889Medicaid