Healthcare Provider Details

I. General information

NPI: 1225568975
Provider Name (Legal Business Name): LIFE CLINIC OF MA PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2017
Last Update Date: 06/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 BOYLSTON ST
CHESTNUT HILL MA
02467-1959
US

IV. Provider business mailing address

PO BOX 686
CHANHASSEN MN
55317-0686
US

V. Phone/Fax

Practice location:
  • Phone: 339-927-4379
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3387
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number22574
License Number StateMA

VIII. Authorized Official

Name: ALBERT COUILLARD
Title or Position: PRESIDENT
Credential: DC
Phone: 339-927-4379