Provider Demographics
NPI:1437462124
Name:ACTIVE CHIROPRACTIC AND WELLNESS
Entity Type:Organization
Organization Name:ACTIVE CHIROPRACTIC AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:703-371-9525
Mailing Address - Street 1:2200 COLONIAL AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23517-1915
Mailing Address - Country:US
Mailing Address - Phone:757-622-8777
Mailing Address - Fax:
Practice Address - Street 1:2200 COLONIAL AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23517-1915
Practice Address - Country:US
Practice Address - Phone:757-622-8777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-22
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556532261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center