MEDICARE: VITAL LIFE CHIROPRACTIC

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	111N00000X	Chiropractor	CHIR009917	GA

General Provider Information

NPI Number	:	1376069476
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VITAL LIFE CHIROPRACTIC

Provider Business Mailing Address
First Line	:	870 CRESTMARK DR STE 202
Second Line	:
City	:	LITHIA SPRINGS
State	:	GA
Zip	:	30122-2665
Country	:	US
Telephone Number	:	404-781-9041
Fax Number	:	678-741-8997

Provider Business Practice Location Address
First Line	:	865 THORNTON RD STE B
Second Line	:
City	:	LITHIA SPRINGS
State	:	GA
Zip	:	30122-2607
Country	:	US
Telephone Number	:	334-321-7275
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	RONNIE EARL BOLAR
Credential	:	DC
Telephone Number	:	334-321-7275

Provider Enumeration Date	:	08/21/2017
Last Update Date	:	03/19/2026

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