Provider Demographics
NPI:1053717538
Name:WAVE OF LIFE CHIROPRACTIC CENTER
Entity type:Organization
Organization Name:WAVE OF LIFE CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CARLY
Authorized Official - Middle Name:
Authorized Official - Last Name:SWIFT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:757-358-0700
Mailing Address - Street 1:3809 JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-1605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4640 SHORE DR
Practice Address - Street 2:STE 106
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-2859
Practice Address - Country:US
Practice Address - Phone:757-358-0700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-12
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104557053111NP0017X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NP0017XChiropractic ProvidersChiropractorPediatric ChiropractorGroup - Single Specialty