Provider Demographics
NPI:1427233485
Name:ACTIVE CHIROPRACTIC CLINIC INC
Entity Type:Organization
Organization Name:ACTIVE CHIROPRACTIC CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:J
Authorized Official - Last Name:KISTLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:317-826-2273
Mailing Address - Street 1:5845 SUNNYSIDE RD
Mailing Address - Street 2:SUITE 800
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46235-8402
Mailing Address - Country:US
Mailing Address - Phone:317-826-2273
Mailing Address - Fax:317-826-2673
Practice Address - Street 1:5845 SUNNYSIDE RD
Practice Address - Street 2:SUITE 800
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46235-8402
Practice Address - Country:US
Practice Address - Phone:317-826-2273
Practice Address - Fax:317-826-2673
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-08
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08001237111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP00006924OtherRR MEDICARE
IN000000344943OtherBCBS
INP00006924OtherRR MEDICARE
IN206410Medicare PIN