Provider Demographics
NPI:1073771176
Name:ACTIVE FAMILY CHIROPARCTIC
Entity Type:Organization
Organization Name:ACTIVE FAMILY CHIROPARCTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BLANCA
Authorized Official - Middle Name:L
Authorized Official - Last Name:QUINTANILLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-689-3500
Mailing Address - Street 1:11790 BARON CAMERON AVE STE J
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20190-5873
Mailing Address - Country:US
Mailing Address - Phone:703-689-3500
Mailing Address - Fax:703-689-3500
Practice Address - Street 1:11790 BARON CAMERON AVE STE J
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20190-5873
Practice Address - Country:US
Practice Address - Phone:703-689-3500
Practice Address - Fax:703-689-3500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-27
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG01137Medicare Oscar/Certification
DCG01137Medicare PIN