Provider Demographics
NPI:1154660199
Name:ACTIVE BODY CHIROPRACTIC & WELLNESS, LLC
Entity Type:Organization
Organization Name:ACTIVE BODY CHIROPRACTIC & WELLNESS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:HOWERTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:816-809-1619
Mailing Address - Street 1:19101 E VALLEY VIEW PKWY STE J
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-6907
Mailing Address - Country:US
Mailing Address - Phone:816-795-0300
Mailing Address - Fax:
Practice Address - Street 1:19101 E VALLEY VIEW PKWY STE J
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055-6907
Practice Address - Country:US
Practice Address - Phone:816-795-0300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-12
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012024639111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP44000004Medicaid