Provider Demographics
NPI:1407047582
Name:ACTIVE FAMILY CHIROPRACTIC
Entity Type:Organization
Organization Name:ACTIVE FAMILY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LORI
Authorized Official - Middle Name:KRISTINE
Authorized Official - Last Name:GOODSELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:763-553-0387
Mailing Address - Street 1:3390 ANNAPOLIS LN N STE C
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-5379
Mailing Address - Country:US
Mailing Address - Phone:763-553-0387
Mailing Address - Fax:
Practice Address - Street 1:3390 ANNAPOLIS LN N STE C
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-5379
Practice Address - Country:US
Practice Address - Phone:763-553-0387
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-05
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3850111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNC03843Medicare PIN