Provider Demographics
NPI:1992986889
Name:LIFE CHIROPRACTIC LLC
Entity type:Organization
Organization Name:LIFE CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:WENDT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:303-678-1979
Mailing Address - Street 1:825 DELAWARE AVE
Mailing Address - Street 2:SUITE P103
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-6169
Mailing Address - Country:US
Mailing Address - Phone:303-678-1979
Mailing Address - Fax:303-678-5577
Practice Address - Street 1:825 DELAWARE AVE
Practice Address - Street 2:SUITE P103
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-6169
Practice Address - Country:US
Practice Address - Phone:303-678-1979
Practice Address - Fax:303-678-5577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6119302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCO40816Medicare PIN