Provider Demographics
NPI:1396057428
Name:ACTIVE REST CHIROPRACTIC
Entity type:Organization
Organization Name:ACTIVE REST CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:COLLAN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:KOEPPEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:858-736-4056
Mailing Address - Street 1:7825 FAY AVE
Mailing Address - Street 2:249
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-4252
Mailing Address - Country:US
Mailing Address - Phone:858-736-4056
Mailing Address - Fax:
Practice Address - Street 1:7825 FAY AVE
Practice Address - Street 2:249
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-4252
Practice Address - Country:US
Practice Address - Phone:858-736-4056
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-06
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty