Provider Demographics
NPI:1346590049
Name:ACTIVE CAROLINA SPORTS AND SPINE, INC.
Entity Type:Organization
Organization Name:ACTIVE CAROLINA SPORTS AND SPINE, INC.
Other - Org Name:CAROLINA PERFORMANCE & WELLNESS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:DANNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:704-541-7499
Mailing Address - Street 1:10440 PARK RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-8504
Mailing Address - Country:US
Mailing Address - Phone:704-541-7499
Mailing Address - Fax:704-541-5565
Practice Address - Street 1:10440 PARK RD
Practice Address - Street 2:SUITE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8504
Practice Address - Country:US
Practice Address - Phone:704-541-7499
Practice Address - Fax:704-541-5565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-11
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3404111N00000X
NC3881111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty