Provider Demographics
NPI:1528725645
Name:LIFE DESIGN CHIROPRACTIC LLC
Entity type:Organization
Organization Name:LIFE DESIGN CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:VINE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:320-349-1650
Mailing Address - Street 1:39041 COUNTY ROAD 2
Mailing Address - Street 2:
Mailing Address - City:HANCOCK
Mailing Address - State:MN
Mailing Address - Zip Code:56244-1215
Mailing Address - Country:US
Mailing Address - Phone:320-766-0880
Mailing Address - Fax:
Practice Address - Street 1:657 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:HANCOCK
Practice Address - State:MN
Practice Address - Zip Code:56244-2104
Practice Address - Country:US
Practice Address - Phone:320-349-1650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-23
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service