Healthcare Provider Details

I. General information

NPI: 1821662941
Provider Name (Legal Business Name): LIFE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2021
Last Update Date: 05/13/2021
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 BARCLAY CIRCLE
MARIETTA GA
30060
US

IV. Provider business mailing address

1415 BARCLAY CIRCLE
MARIETTA GA
30060
US

V. Phone/Fax

Practice location:
  • Phone: 770-792-6100
  • Fax:
Mailing address:
  • Phone: 770-792-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

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