Provider Demographics
NPI:1316961915
Name:ACTIVE CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:ACTIVE CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:B
Authorized Official - Last Name:WASSMER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:321-255-3003
Mailing Address - Street 1:1251 HICKORY ST
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-3221
Mailing Address - Country:US
Mailing Address - Phone:321-255-3003
Mailing Address - Fax:321-255-3005
Practice Address - Street 1:1251 HICKORY ST
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3221
Practice Address - Country:US
Practice Address - Phone:321-255-3003
Practice Address - Fax:321-255-3005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH9223111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty