Provider Demographics
NPI:1104221530
Name:ACTIVE FAMILY CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:ACTIVE FAMILY CHIROPRACTIC, LLC
Other - Org Name:ACTIVE FAMILY CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:K
Authorized Official - Last Name:WAGGONER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-674-7894
Mailing Address - Street 1:501 NE HOOD AVE
Mailing Address - Street 2:SUITE 205
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-7303
Mailing Address - Country:US
Mailing Address - Phone:503-674-7894
Mailing Address - Fax:503-674-7899
Practice Address - Street 1:501 NE HOOD AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7303
Practice Address - Country:US
Practice Address - Phone:503-674-7894
Practice Address - Fax:503-674-7899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-28
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3725111NP0017X
OR3666111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
No111NP0017XChiropractic ProvidersChiropractorPediatric ChiropractorGroup - Multi-Specialty