Healthcare Provider Details

I. General information

NPI: 1063033942
Provider Name (Legal Business Name): LIFE UNIVERSITY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2020
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BALTIMORE P1. NW SUITE 100
ATLANTA GA
30308
US

IV. Provider business mailing address

1415 BARCLAY CIR SE STE 100
MARIETTA GA
30060-2943
US

V. Phone/Fax

Practice location:
  • Phone: 678-331-4500
  • Fax: 678-331-4500
Mailing address:
  • Phone: 770-426-2786
  • Fax: 770-792-6113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. TAMMY AILEEN CAGLE
Title or Position: DIRECTOR OF BUSINESS
Credential:
Phone: 770-426-2786