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General NPI Number Information
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NPI Number | 1508234345
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Entity Type | Organization
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Legal Business Name | CHIROPRACTIC LIFE CENTER, P.A.
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Dates
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Enumeration Date | 09/10/2015
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Last Update Date | 09/10/2015
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Provider Practice Location Address
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Address Line | 3427 MARINER BLVD
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City | SPRING HILL
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State | FL
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Zip | 34609-2463
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Country | US
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Telephone | 352-686-2554
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Fax | 352-686-3302
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Provider Business Mailing Address
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Address Line | 3427 MARINER BLVD
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City | SPRING HILL
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State | FL
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Zip | 34609-2463
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Country | US
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Telephone | 352-686-2554
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Fax | 352-686-3302
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Authorized Official
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Title or Position | OWNER/PHYSICIAN
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Name | DR. CHARLES R. GLENN
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Credential | D.C.
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Telephone | 352-686-2554
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number |
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License Number State |
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