Provider Demographics
NPI:1194801191
Name:ACTIVE LIFESTYLE CHIROPRACTIC,SC
Entity type:Organization
Organization Name:ACTIVE LIFESTYLE CHIROPRACTIC,SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:GRUSZKA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-787-0122
Mailing Address - Street 1:PO BOX 246
Mailing Address - Street 2:
Mailing Address - City:WAUTOMA
Mailing Address - State:WI
Mailing Address - Zip Code:54982-0246
Mailing Address - Country:US
Mailing Address - Phone:920-787-0122
Mailing Address - Fax:920-787-0091
Practice Address - Street 1:140 N. TOWNLINE RD.
Practice Address - Street 2:
Practice Address - City:WAUTOMA
Practice Address - State:WI
Practice Address - Zip Code:54982-0246
Practice Address - Country:US
Practice Address - Phone:920-787-0122
Practice Address - Fax:920-787-0091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3391111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty