Provider Demographics
NPI:1477075182
Name:HEATH ACTIVE SPINE & REHAB LLC
Entity Type:Organization
Organization Name:HEATH ACTIVE SPINE & REHAB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GUSTAFSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:440-319-5520
Mailing Address - Street 1:838 S 30TH ST
Mailing Address - Street 2:
Mailing Address - City:HEATH
Mailing Address - State:OH
Mailing Address - Zip Code:43056-1254
Mailing Address - Country:US
Mailing Address - Phone:740-522-6300
Mailing Address - Fax:740-522-6308
Practice Address - Street 1:838 S 30TH ST
Practice Address - Street 2:
Practice Address - City:HEATH
Practice Address - State:OH
Practice Address - Zip Code:43056-1254
Practice Address - Country:US
Practice Address - Phone:740-522-6300
Practice Address - Fax:740-522-6308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHDC-04383111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty