Provider Demographics
NPI:1104095173
Name:ACTIVE PERFORMANCE CHIROPRACTIC
Entity type:Organization
Organization Name:ACTIVE PERFORMANCE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:B
Authorized Official - Last Name:BOVEE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:570-814-5593
Mailing Address - Street 1:3 N RIVER ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PLAINS
Mailing Address - State:PA
Mailing Address - Zip Code:18705-1334
Mailing Address - Country:US
Mailing Address - Phone:866-793-9788
Mailing Address - Fax:877-587-4487
Practice Address - Street 1:3 N RIVER ST
Practice Address - Street 2:SUITE 104
Practice Address - City:PLAINS
Practice Address - State:PA
Practice Address - Zip Code:18705-1334
Practice Address - Country:US
Practice Address - Phone:866-793-9788
Practice Address - Fax:877-587-4487
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-25
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC009871111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty