Provider Demographics
NPI:1417297227
Name:ACTIVE CARE CHIROPRACTIC PLLC
Entity Type:Organization
Organization Name:ACTIVE CARE CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:BLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:405-455-5778
Mailing Address - Street 1:1405 S DOUGLAS BLVD
Mailing Address - Street 2:SUITE E
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-5267
Mailing Address - Country:US
Mailing Address - Phone:405-455-5778
Mailing Address - Fax:405-455-5408
Practice Address - Street 1:1405 S DOUGLAS BLVD
Practice Address - Street 2:SUITE E
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-5267
Practice Address - Country:US
Practice Address - Phone:405-455-5778
Practice Address - Fax:405-455-5408
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ACTIVE CARE CHIROPRACTIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-02-15
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3801111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200522114Medicare UPIN