Provider Demographics
NPI:1053614586
Name:PURE LIFE CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:PURE LIFE CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:NYBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:541-343-5633
Mailing Address - Street 1:1400 VALLEY RIVER DR STE 260
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-6760
Mailing Address - Country:US
Mailing Address - Phone:541-343-5633
Mailing Address - Fax:541-762-5633
Practice Address - Street 1:1400 VALLEY RIVER DR STE 260
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-6760
Practice Address - Country:US
Practice Address - Phone:541-343-5633
Practice Address - Fax:541-762-5633
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-06
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3808111N00000X
111N00000X, 171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1508924523OtherNPI (NATIONAL PROVIDER IDENTIFICATION)