Provider Demographics
NPI:1467745190
Name:PRO ACTIVE CHIROPRACTIC
Entity Type:Organization
Organization Name:PRO ACTIVE CHIROPRACTIC
Other - Org Name:DAVID BOLTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER, CHIROPRACTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:LOWELL
Authorized Official - Last Name:BOLTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:626-335-1007
Mailing Address - Street 1:340 S GLENDORA AVE
Mailing Address - Street 2:SUITE #4
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-6255
Mailing Address - Country:US
Mailing Address - Phone:626-335-1007
Mailing Address - Fax:626-335-1002
Practice Address - Street 1:340 S GLENDORA AVE
Practice Address - Street 2:SUITE #4
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-6255
Practice Address - Country:US
Practice Address - Phone:626-335-1007
Practice Address - Fax:626-335-1002
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-27
Last Update Date:2011-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC29572111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty