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General NPI Number Information
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NPI Number | 1730539065
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Entity Type | Organization
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Legal Business Name | LIVE TILL 100, INC.
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Dates
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Enumeration Date | 06/17/2016
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Last Update Date | 06/17/2016
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Provider Practice Location Address
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Address Line | 7895 WESTMINSTER BLVD
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City | WESTMINSTER
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State | CA
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Zip | 92683-4043
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Country | US
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Telephone | 714-893-1222
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Fax | 714-893-1244
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Provider Business Mailing Address
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Address Line | 7695 ENCINAS CIR
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City | WESTMINSTER
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State | CA
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Zip | 92683-3210
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Country | US
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Telephone | 714-470-6911
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | DR. MITZIE LAM
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Credential | DC
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Telephone | 714-470-6911
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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 | DC30128
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License Number State | CA
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