MEDICARE: SPRING OF LIFE CHIROPRACTIC LLC

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	0104557252	VA

General Provider Information

NPI Number	:	1609247873
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPRING OF LIFE CHIROPRACTIC LLC

Provider Business Mailing Address
First Line	:	1101 BATTLEFIELD BLVD N
Second Line	:
City	:	CHESAPEAKE
State	:	VA
Zip	:	23320-4735
Country	:	US
Telephone Number	:	757-560-7987
Fax Number	:

Provider Business Practice Location Address
First Line	:	1101 BATTLEFIELD BLVD N
Second Line	:
City	:	CHESAPEAKE
State	:	VA
Zip	:	23320-4735
Country	:	US
Telephone Number	:	757-560-7987
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. CLINTON BANEY
Credential	:	DC
Telephone Number	:	757-560-7987

Provider Enumeration Date	:	10/14/2015
Last Update Date	:	10/14/2015

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