Healthcare Provider Details

I. General information

NPI: 1124469341
Provider Name (Legal Business Name): LIFE SPROUT CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/16/2013
Last Update Date: 10/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

912 BARNETTE ST
FAIRBANKS AK
99701-4510
US

IV. Provider business mailing address

505 ILLINOIS ST STE 4
FAIRBANKS AK
99701-2946
US

V. Phone/Fax

Practice location:
  • Phone: 907-451-7000
  • Fax: 907-891-7297
Mailing address:
  • Phone: 907-451-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number568
License Number StateAK

VIII. Authorized Official

Name: DR. ALEXANDRA F SWENSON
Title or Position: OWNER/CHIROPRACTOR
Credential: DC
Phone: 907-451-7000