Provider Demographics
NPI:1811350572
Name:ACTIVE LIFE CHIROPRACTIC & MASSAGE CENTER LLC
Entity type:Organization
Organization Name:ACTIVE LIFE CHIROPRACTIC & MASSAGE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER/CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:SPICZENSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:740-359-9560
Mailing Address - Street 1:520 W ALDINE AVE
Mailing Address - Street 2:411
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-3768
Mailing Address - Country:US
Mailing Address - Phone:740-359-9560
Mailing Address - Fax:
Practice Address - Street 1:209 MAIN STREET
Practice Address - Street 2:UNIT E
Practice Address - City:MEAD
Practice Address - State:CO
Practice Address - Zip Code:80542
Practice Address - Country:US
Practice Address - Phone:970-535-9900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILCHR.0007418111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty