Provider Demographics
NPI:1528879145
Name:ACTIVE LIFE MOBILE CHIROPRACTIC INC
Entity type:Organization
Organization Name:ACTIVE LIFE MOBILE CHIROPRACTIC INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER ACTIVE LIFE MOBILE CHIROPRACT
Authorized Official - Prefix:DR
Authorized Official - First Name:GIL
Authorized Official - Middle Name:P
Authorized Official - Last Name:KENTOF
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:615-969-8663
Mailing Address - Street 1:PO BOX 865 OURAY, CO 81427
Mailing Address - Street 2:
Mailing Address - City:OURAY
Mailing Address - State:CO
Mailing Address - Zip Code:81427
Mailing Address - Country:US
Mailing Address - Phone:615-969-8663
Mailing Address - Fax:
Practice Address - Street 1:801 MAIN STREET
Practice Address - Street 2:
Practice Address - City:OURAY
Practice Address - State:CO
Practice Address - Zip Code:81427
Practice Address - Country:US
Practice Address - Phone:615-969-8663
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-14
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty