Provider Demographics
NPI:1063558849
Name:ACTIVE BACK PAIN RELIEF CENTER LLC
Entity type:Organization
Organization Name:ACTIVE BACK PAIN RELIEF CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:E
Authorized Official - Last Name:JOHNSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:413-737-7787
Mailing Address - Street 1:82 MAIN STREET
Mailing Address - Street 2:SUITE 8
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01089
Mailing Address - Country:US
Mailing Address - Phone:413-737-7787
Mailing Address - Fax:413-737-7789
Practice Address - Street 1:82 MAIN STREET
Practice Address - Street 2:SUITE 8
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089
Practice Address - Country:US
Practice Address - Phone:413-737-7787
Practice Address - Fax:413-737-7789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1917111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAY39217OtherBLUE CROSS BLUE SHIELD