Provider Demographics
NPI:1194149203
Name:ACTIVE CHIROPRACTIC P C
Entity type:Organization
Organization Name:ACTIVE CHIROPRACTIC P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:DORNBUSH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:563-242-9343
Mailing Address - Street 1:1001 13TH AVE N
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52732-3403
Mailing Address - Country:US
Mailing Address - Phone:563-242-9343
Mailing Address - Fax:
Practice Address - Street 1:1001 13TH AVE N
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732-3403
Practice Address - Country:US
Practice Address - Phone:563-242-9343
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-10
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA06166111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2180513Medicaid
IAI4266Medicare PIN
IA2180513Medicaid