Provider Demographics
NPI:1992988216
Name:VITALITY LIFE CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:VITALITY LIFE CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:952-835-4772
Mailing Address - Street 1:4444 W 76TH ST
Mailing Address - Street 2:400
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5173
Mailing Address - Country:US
Mailing Address - Phone:952-835-4772
Mailing Address - Fax:763-207-8381
Practice Address - Street 1:7250 FRANCE AVE S
Practice Address - Street 2:300A
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-5173
Practice Address - Country:US
Practice Address - Phone:952-835-4772
Practice Address - Fax:763-207-8381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4989111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3I334VIOtherBCBS
MNCC1343AOtherCHIROCARE
MN060468000OtherMHCP
MNCC1343AOtherCHIROCARE