Provider Demographics
NPI:1679937601
Name:LIFECLINIC PHYSICAL THERAPY & CHIROPRACTIC LLC
Entity type:Organization
Organization Name:LIFECLINIC PHYSICAL THERAPY & CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REZA
Authorized Official - Middle Name:POUR
Authorized Official - Last Name:ALIZADEH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:612-868-6894
Mailing Address - Street 1:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:CHANHASSEN
Mailing Address - State:MN
Mailing Address - Zip Code:55317-0549
Mailing Address - Country:US
Mailing Address - Phone:952-229-7558
Mailing Address - Fax:952-474-1504
Practice Address - Street 1:1499 YAMATO RD
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33431-4435
Practice Address - Country:US
Practice Address - Phone:561-208-5900
Practice Address - Fax:952-474-1504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-06
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty