Healthcare Provider Details

I. General information

NPI: 1437666914
Provider Name (Legal Business Name): AUTHENTIC LIFE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2018
Last Update Date: 01/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11960 WEST 119TH STREET
OVERLAND PARK KS
66213
US

IV. Provider business mailing address

11960 WEST 119TH STREET
OVERLAND PARK KS
66213
US

V. Phone/Fax

Practice location:
  • Phone: 913-563-4621
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number04640
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number04604
License Number StateKS

VIII. Authorized Official

Name: DR. GEORGIA J NAB
Title or Position: OWNER/CHIEF CLINICAL OFFICER
Credential: DC
Phone: 913-562-4621