Healthcare Provider Details

I. General information

NPI: 1750931267
Provider Name (Legal Business Name): LIFE CLINIC OF AZ PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2019
Last Update Date: 09/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2580 E CAMELBACK RD
PHOENIX AZ
85016-4204
US

IV. Provider business mailing address

PO BOX 549
CHANHASSEN MN
55317-0549
US

V. Phone/Fax

Practice location:
  • Phone: 952-229-7464
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: REZA ALIZADEH
Title or Position: PRESIDENT
Credential:
Phone: 952-229-7464