Provider Demographics
NPI:1164693644
Name:ACTIVE ROLE CHIROPRACTIC PC
Entity Type:Organization
Organization Name:ACTIVE ROLE CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:DAIL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:517-321-3030
Mailing Address - Street 1:722 N CREYTS RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-8608
Mailing Address - Country:US
Mailing Address - Phone:517-321-3030
Mailing Address - Fax:
Practice Address - Street 1:722 N CREYTS RD
Practice Address - Street 2:SUITE B
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-8608
Practice Address - Country:US
Practice Address - Phone:517-321-3030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-12
Last Update Date:2012-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301009419111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty