Provider Demographics
NPI:1447848288
Name:LIFE DESIGN CHIROPRACTIC, PLLC
Entity type:Organization
Organization Name:LIFE DESIGN CHIROPRACTIC, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:VINE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:406-946-1813
Mailing Address - Street 1:222 E MAIN ST # 1-C
Mailing Address - Street 2:
Mailing Address - City:ENNIS
Mailing Address - State:MT
Mailing Address - Zip Code:59729-9229
Mailing Address - Country:US
Mailing Address - Phone:406-946-1813
Mailing Address - Fax:
Practice Address - Street 1:222 E MAIN ST # 1-C
Practice Address - Street 2:
Practice Address - City:ENNIS
Practice Address - State:MT
Practice Address - Zip Code:59729-9229
Practice Address - Country:US
Practice Address - Phone:406-946-1813
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-07
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty