MEDICARE: LIFE CLINIC OF OK PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist
2	111N00000X	Chiropractor

General Provider Information

NPI Number	:	1194293233
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE CLINIC OF OK PC

Provider Business Mailing Address
First Line	:	PO BOX 549
Second Line	:
City	:	CHANHASSEN
State	:	MN
Zip	:	55317-0549
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2563 W MEMORIAL RD
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73134-8030
Country	:	US
Telephone Number	:	952-229-7464
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	AARON BURK
Credential	:	DC
Telephone Number	:	952-229-7464

Provider Enumeration Date	:	11/07/2018
Last Update Date	:	11/07/2018

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