Provider Demographics
NPI:1720422462
Name:ACTIVE CHIROPRACTIC LLC
Entity type:Organization
Organization Name:ACTIVE CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:937-689-4601
Mailing Address - Street 1:43 SOLOMONS ISLAND ROAD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3852
Mailing Address - Country:US
Mailing Address - Phone:410-266-3888
Mailing Address - Fax:
Practice Address - Street 1:43 SOLOMONS ISLAND ROAD
Practice Address - Street 2:SUITE 201
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3852
Practice Address - Country:US
Practice Address - Phone:410-266-3888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-24
Last Update Date:2013-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDS03744111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty