Provider Demographics
NPI:1336423334
Name:ACTIVE FAMILY & SPORTS CHIROPRACTIC PLLC
Entity type:Organization
Organization Name:ACTIVE FAMILY & SPORTS CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JUDE
Authorized Official - Middle Name:AARON
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC, MS
Authorized Official - Phone:865-248-8167
Mailing Address - Street 1:1260 GALLAHER RD
Mailing Address - Street 2:SUITE B & C
Mailing Address - City:KINGSTON
Mailing Address - State:TN
Mailing Address - Zip Code:37763-4139
Mailing Address - Country:US
Mailing Address - Phone:865-248-8167
Mailing Address - Fax:865-248-8215
Practice Address - Street 1:1260 GALLAHER RD
Practice Address - Street 2:SUITE B & C
Practice Address - City:KINGSTON
Practice Address - State:TN
Practice Address - Zip Code:37763-4139
Practice Address - Country:US
Practice Address - Phone:865-382-3014
Practice Address - Fax:865-248-8215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-09
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2547111N00000X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103G705790Medicare UPIN