Healthcare Provider Details

I. General information

NPI: 1558377929
Provider Name (Legal Business Name): LIFE FAMILY CHIROPRACTIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1060 CENTERVILLE CIR
VADNAIS HEIGHTS MN
55127-6344
US

IV. Provider business mailing address

1060 CENTERVILLE CIR
VADNAIS HEIGHTS MN
55127-6344
US

V. Phone/Fax

Practice location:
  • Phone: 651-429-3015
  • Fax: 651-653-3832
Mailing address:
  • Phone: 651-429-3015
  • Fax: 651-653-3832

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4771
License Number StateMN

VIII. Authorized Official

Name: DR. NATHANIEL ELI POCHUCHA
Title or Position: CEO
Credential: D.C.
Phone: 651-429-3015