MEDICARE: LIFECLINIC CHIROPRACTIC OF NEVADA 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

General Provider Information

NPI Number	:	1861735755
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFECLINIC CHIROPRACTIC OF NEVADA LLC

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

Provider Business Practice Location Address
First Line	:	121 CARNEGIE STREET
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89052-7118
Country	:	US
Telephone Number	:	952-229-7558
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	REZA POUR ALIZADEH
Credential	:	DC
Telephone Number	:	651-690-0866

Provider Enumeration Date	:	03/29/2013
Last Update Date	:	10/13/2015

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