Provider Demographics
NPI:1366706053
Name:CONDITION FOR LIFE
Entity type:Organization
Organization Name:CONDITION FOR LIFE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:R
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:541-887-2223
Mailing Address - Street 1:335 S SPRING ST
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97601-5947
Mailing Address - Country:US
Mailing Address - Phone:541-887-2223
Mailing Address - Fax:541-887-2228
Practice Address - Street 1:335 S SPRING ST
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97601-5947
Practice Address - Country:US
Practice Address - Phone:541-887-2223
Practice Address - Fax:541-887-2228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-27
Last Update Date:2019-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2714111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR166598Medicare PIN