Provider Demographics
NPI:1033518600
Name:ACTIVE WELLNESS CHIROPRACTIC,PC
Entity Type:Organization
Organization Name:ACTIVE WELLNESS CHIROPRACTIC,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEJANA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-789-1014
Mailing Address - Street 1:1815 SW MARLOW AVE
Mailing Address - Street 2:SUITE 206
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97225-5185
Mailing Address - Country:US
Mailing Address - Phone:503-789-1014
Mailing Address - Fax:877-985-9111
Practice Address - Street 1:1815 SW MARLOW AVE
Practice Address - Street 2:SUITE 206
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-5185
Practice Address - Country:US
Practice Address - Phone:503-789-1014
Practice Address - Fax:877-985-9111
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-19
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3632111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1871506600OtherNPI TYPE 1