=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417347899
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIFECLINIC CHIROPRACTIC OF TEXAS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2015
-----------------------------------------------------
Last Update Date | 01/23/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 971 SAM RAYBURN TOLLWAY
-----------------------------------------------------
City | ALLEN
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75013-6004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-229-7925
-----------------------------------------------------
Fax | 952-474-1504
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 33 HAMLINE AVE S
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55105-2231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-229-7925
-----------------------------------------------------
Fax | 952-474-1504
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/D.C
-----------------------------------------------------
Name | DR. REZA ALIZADEH
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 612-868-6894
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 03221
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------