Healthcare Provider Details

I. General information

NPI: 1992986889
Provider Name (Legal Business Name): LIFE CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2007
Last Update Date: 04/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 DELAWARE AVE SUITE P103
LONGMONT CO
80501-6169
US

IV. Provider business mailing address

825 DELAWARE AVE SUITE P103
LONGMONT CO
80501-6169
US

V. Phone/Fax

Practice location:
  • Phone: 303-678-1979
  • Fax: 303-678-5577
Mailing address:
  • Phone: 303-678-1979
  • Fax: 303-678-5577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number6119
License Number StateCO

VIII. Authorized Official

Name: DR. JOHN R. WENDT
Title or Position: OWNER
Credential: D.C.
Phone: 303-678-1979