Provider Demographics
NPI:1225437080
Name:ACTIVE LIFE CHIROPRACTIC, PLLC
Entity Type:Organization
Organization Name:ACTIVE LIFE CHIROPRACTIC, PLLC
Other - Org Name:COAST SPINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:IRVIN
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:IV
Authorized Official - Credentials:DC
Authorized Official - Phone:772-873-8595
Mailing Address - Street 1:518 SE OSCEOLA ST
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-2322
Mailing Address - Country:US
Mailing Address - Phone:772-873-8595
Mailing Address - Fax:772-873-8597
Practice Address - Street 1:518 SE OSCEOLA ST
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-2322
Practice Address - Country:US
Practice Address - Phone:772-873-8595
Practice Address - Fax:772-873-8597
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-18
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 11181111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Single Specialty