Healthcare Provider Details

I. General information

NPI: 1437650843
Provider Name (Legal Business Name): LIFE CLINIC OF NC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2018
Last Update Date: 07/19/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8515 FALLS OF NEUSE RD
RALEIGH NC
27615-3513
US

IV. Provider business mailing address

PO BOX 549
CHANHASSEN MN
55317-0549
US

V. Phone/Fax

Practice location:
  • Phone: 952-229-7558
  • Fax: 952-474-1504
Mailing address:
  • Phone: 952-229-7464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3029
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number8759
License Number StateTN

VIII. Authorized Official

Name: DR. REZA ALIZADEH
Title or Position: PRESIDENT
Credential: DC
Phone: 952-229-7464