Basic Information
| Provider Information | |||||||||
| NPI: | 1205229788 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MY LIFE CHIROPRACTIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1393 GEORGE DIETER DR | ||||||||
| Address2: | STE. E | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799367410 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1393 GEORGE DIETER DR | ||||||||
| Address2: | STE. E | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799367410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9152284915 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2015 | ||||||||
| LastUpdateDate: | 03/09/2015 | ||||||||
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| AuthorizedOfficialLastName: | LEYVA | ||||||||
| AuthorizedOfficialFirstName: | BENJAMIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 9152284915 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 12746 | TX | Y | 193400000X SINGLE SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
No ID Information.