Provider Demographics
NPI:1114155819
Name:ACTIVE CHIROPRACTIC P.C
Entity Type:Organization
Organization Name:ACTIVE CHIROPRACTIC P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:HOSS
Authorized Official - Middle Name:
Authorized Official - Last Name:MANSOORI
Authorized Official - Suffix:
Authorized Official - Credentials:CHIROPRACTIC
Authorized Official - Phone:214-553-5543
Mailing Address - Street 1:11615 FOREST CENTRAL DR
Mailing Address - Street 2:214
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-3921
Mailing Address - Country:US
Mailing Address - Phone:214-553-5543
Mailing Address - Fax:214-553-5531
Practice Address - Street 1:11615 FOREST CENTRAL DR
Practice Address - Street 2:214
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-3921
Practice Address - Country:US
Practice Address - Phone:214-553-5543
Practice Address - Fax:214-553-5531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-01
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10190111NI0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NI0900XChiropractic ProvidersChiropractorInternistGroup - Single Specialty