Provider Demographics
NPI:1326464470
Name:ACTIVE WELLNESS CHIROPRACTIC PC
Entity Type:Organization
Organization Name:ACTIVE WELLNESS CHIROPRACTIC PC
Other - Org Name:HEALTHSOURCE OF NORFOLK
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:757-627-2222
Mailing Address - Street 1:1900 MONTICELLO AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23517-2339
Mailing Address - Country:US
Mailing Address - Phone:757-627-2222
Mailing Address - Fax:
Practice Address - Street 1:1900 MONTICELLO AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23517-2339
Practice Address - Country:US
Practice Address - Phone:757-627-2222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-13
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104002072111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty