Provider Demographics
NPI:1518130319
Name:ACTIVE SPINE & SPORT THERAPY PC
Entity Type:Organization
Organization Name:ACTIVE SPINE & SPORT THERAPY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:DAVID
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:480-726-3305
Mailing Address - Street 1:1445 S ARIZONA AVE STE 12
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85286-6509
Mailing Address - Country:US
Mailing Address - Phone:480-726-3055
Mailing Address - Fax:480-726-3508
Practice Address - Street 1:1445 S ARIZONA AVE STE 12
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85286-6509
Practice Address - Country:US
Practice Address - Phone:480-726-3305
Practice Address - Fax:480-726-3508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-12
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7573111N00000X
AZ6628225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ122175Medicare PIN