Provider Demographics
NPI:1063500254
Name:ACTIVE HEALTH CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:ACTIVE HEALTH CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIK
Authorized Official - Middle Name:MATHEW
Authorized Official - Last Name:FOTHERINGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:248-922-3334
Mailing Address - Street 1:7743 SASHABAW RD
Mailing Address - Street 2:UNIT F
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-4775
Mailing Address - Country:US
Mailing Address - Phone:248-922-3334
Mailing Address - Fax:248-922-3336
Practice Address - Street 1:7743 SASHABAW RD
Practice Address - Street 2:UNIT F
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48348-4775
Practice Address - Country:US
Practice Address - Phone:248-922-3334
Practice Address - Fax:248-922-3336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301008671111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P08880Medicare ID - Type UnspecifiedCHIROPRACTIC