Provider Demographics
NPI:1144672031
Name:LIFE ADVANTAGE CHIROPRACTIC
Entity type:Organization
Organization Name:LIFE ADVANTAGE CHIROPRACTIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:ULLOA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:815-630-6461
Mailing Address - Street 1:1210 DOUGLAS RD
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-7918
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1210 DOUGLAS RD
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-7918
Practice Address - Country:US
Practice Address - Phone:630-608-2885
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-05
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty