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General NPI Number Information
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NPI Number | 1689844524
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Entity Type | Organization
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Legal Business Name | LIFEWISE PHYSICAL MEDICINE CENTER, LLC
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Dates
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Enumeration Date | 03/06/2008
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Last Update Date | 11/06/2008
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Provider Practice Location Address
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Address Line | 4633 BRAMBLETON AVE
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City | ROANOKE
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State | VA
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Zip | 24018-3410
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Country | US
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Telephone | 540-400-7733
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Fax | 540-904-6009
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Provider Business Mailing Address
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Address Line | 4633 BRAMBLETON AVE
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City | ROANOKE
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State | VA
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Zip | 24018-3410
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Country | US
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Telephone | 540-400-7733
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Fax | 540-904-6009
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Authorized Official
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Title or Position | OWNER
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Name | DR. RHETT TRAVIS
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Credential | D.C.
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Telephone | 540-400-7733
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NR0400X
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Taxonomy Name | Rehabilitation Chiropractor
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License Number | 0104001882
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License Number State | VA
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