Provider Demographics
NPI:1073291811
Name:ACTIVE REHAB CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:ACTIVE REHAB CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARSHALL
Authorized Official - Middle Name:
Authorized Official - Last Name:GEVERS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-520-8270
Mailing Address - Street 1:4225 S STATE ROUTE 159 STE 2
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-3231
Mailing Address - Country:US
Mailing Address - Phone:618-641-3111
Mailing Address - Fax:
Practice Address - Street 1:4225 S STATE ROUTE 159 STE 2
Practice Address - Street 2:
Practice Address - City:GLEN CARBON
Practice Address - State:IL
Practice Address - Zip Code:62034-3231
Practice Address - Country:US
Practice Address - Phone:618-641-3111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-11
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty