Healthcare Provider Details

I. General information

NPI: 1508234345
Provider Name (Legal Business Name): CHIROPRACTIC LIFE CENTER, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2015
Last Update Date: 09/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3427 MARINER BLVD
SPRING HILL FL
34609-2463
US

IV. Provider business mailing address

3427 MARINER BLVD
SPRING HILL FL
34609-2463
US

V. Phone/Fax

Practice location:
  • Phone: 352-686-2554
  • Fax: 352-686-3302
Mailing address:
  • Phone: 352-686-2554
  • Fax: 352-686-3302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: DR. CHARLES R. GLENN
Title or Position: OWNER/PHYSICIAN
Credential: D.C.
Phone: 352-686-2554