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General NPI Number Information
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NPI Number | 1992216295
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Entity Type | Organization
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Legal Business Name | VITALITY LIFE CHIROPRACTIC, LLC
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Dates
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Enumeration Date | 10/13/2017
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Last Update Date | 10/27/2017
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Provider Practice Location Address
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Address Line | 7250 FRANCE AVE S, STE 300A
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City | EDINA
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State | MN
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Zip | 55435-4305
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Country | US
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Telephone | 952-835-4772
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Fax | 763-207-8381
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Provider Business Mailing Address
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Address Line | 7250 FRANCE AVE S. 300A
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City | EDINA
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State | MN
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Zip | 55435-4346
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Country | US
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Telephone | 952-835-4772
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Fax | 763-207-8381
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Authorized Official
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Title or Position | OWNER
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Name | DR. JASON LEE ELLIS
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Credential | D.C.
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Telephone | 952-835-4772
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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 | 4989
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License Number State | MN
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