Provider Demographics
NPI:1083905301
Name:ACTIVE LIFESTYLE CHIROPRACTIC
Entity Type:Organization
Organization Name:ACTIVE LIFESTYLE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:WINTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:480-704-1050
Mailing Address - Street 1:16515 S 40TH ST
Mailing Address - Street 2:SUITE 129
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-0558
Mailing Address - Country:US
Mailing Address - Phone:480-704-1050
Mailing Address - Fax:480-704-0109
Practice Address - Street 1:16515 S 40TH ST
Practice Address - Street 2:SUITE 129
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85048-0558
Practice Address - Country:US
Practice Address - Phone:480-704-1050
Practice Address - Fax:480-704-0109
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-20
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7750111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z111783OtherPTAN
AZU98818Medicare UPIN
Z111783OtherPTAN