Provider Demographics
NPI:1063832798
Name:ACTIVE HEALTH EAU CLAIRE
Entity Type:Organization
Organization Name:ACTIVE HEALTH EAU CLAIRE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JUDY
Authorized Official - Middle Name:
Authorized Official - Last Name:SOBOROWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:715-834-6333
Mailing Address - Street 1:3521 LONDON RD
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-7861
Mailing Address - Country:US
Mailing Address - Phone:715-834-6333
Mailing Address - Fax:715-831-6374
Practice Address - Street 1:3521 LONDON RD
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-7861
Practice Address - Country:US
Practice Address - Phone:715-834-6333
Practice Address - Fax:715-831-6374
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-21
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3103111N00000X
WI3207111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI000070863OtherPTAN
WI1104883404Medicaid
WI1255442729Medicaid
WI1255442729Medicaid
WI1104883404Medicaid
WI000070863OtherPTAN