Provider Demographics
NPI:1144658808
Name:NEW LIFE CHIROPRACTIC CENTER LLC
Entity type:Organization
Organization Name:NEW LIFE CHIROPRACTIC CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-450-7632
Mailing Address - Street 1:4036-B3 RIVER OAKS DR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-6615
Mailing Address - Country:US
Mailing Address - Phone:843-450-7632
Mailing Address - Fax:
Practice Address - Street 1:4036 RIVER OAKS DR # B3
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-6695
Practice Address - Country:US
Practice Address - Phone:843-450-7632
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-16
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCDC.3833 DC111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty