=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548045727
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHIROLIFE WELLNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2023
-----------------------------------------------------
Last Update Date | 08/28/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 310 THIRD ST STE B
-----------------------------------------------------
City | PORT ST JOE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32456-1834
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-673-0604
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 240 SEA GROVE WAY
-----------------------------------------------------
City | PORT ST JOE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32456-4831
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 479-721-5824
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KELLEY HENSLEY
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 479-721-5824
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------